Specialty Overview by Prior Authorization Approval or Denial 2nd Quarter 2016

Transcription

1 Specialty Overview by Prior Authorization Approval or 2nd Quarter DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/ DERMATOLOGY Stelara PSORIASIS Approval Approved from 04/26/2016 thru 04/26/ FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS No Response 3961 FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/29/2016 thru 04/29/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/12/2016 thru 04/12/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/18/2016 thru 04/18/ HEMATOLOGY & ONCOLOGY Inlyta ONCOLOGY Approval Approved from 04/27/2016 thru 04/27/ NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 04/01/2016 thru 05/01/ NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 04/25/2016 thru 04/25/ NEUROLOGY Betaseron MULTIPLE SCLEROSIS Approval 3961 Repatha Approved from 04/29/2016 thru 04/29/2018 No Response 3961 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response 3961 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response 3961 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/08/2016 thru 04/08/ RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/28/2016 thru 04/28/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/04/2016 thru 06/04/ HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY 3961 HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Ibrance and letrozole (Femara) if letrozole is not being used as initial endocrine based therapy in the setting of metastatic/advanced disease. Thao Trinh, Pharm.D, TX License # Approved x 12 months. Approved from 05/16/2016 thru 05/16/ HEMATOLOGY & ONCOLOGY Tikosyn CARDIAC DISORDERS Approval Approved from 05/27/2016 thru 05/27/ INTERNAL MEDICINE Norditropin 3961 INTERNAL MEDICINE Norditropin No Response Approval Approved from 05/06/2016 thru 05/06/2017 1

2 3961 INTERNAL MEDICINE Sensipar RENAL DISEASE Approval Approved from 05/25/2016 thru 05/25/ NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE No Response Sensipar RENAL DISEASE Approval Approved from 05/11/2016 thru 05/11/2017 Sensipar RENAL DISEASE Approval Approved from 05/11/2016 thru 05/11/2017 Sensipar RENAL DISEASE Approval Approved from 05/12/2016 thru 05/12/2017 Sensipar RENAL DISEASE Approval Approved from 05/16/2016 thru 05/16/2017 Cimzia INFLAMMATORY BOWEL DISEASE No Response 3961 RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Approval Approved from 05/02/2016 thru 05/02/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/18/2016 thru 05/18/ RHEUMATOLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 05/24/2016 thru 05/24/ RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/24/2016 thru 05/24/ ENDOCRINOLOGY, PEDIATRIC Norditropin Approval Approved x 12 months. Approved from 06/21/2016 thru 06/21/ FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/10/2016 thru 06/10/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/19/2016 thru 06/19/ HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 06/16/2016 thru 06/16/ HEMATOLOGY & ONCOLOGY Thalomid ONCOLOGY Approval Approved from 06/16/2016 thru 06/16/ HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Approved from 06/23/2016 thru 06/23/ INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 06/25/2016 thru 06/25/ NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 07/19/2016 thru 07/19/ PULMONARY DISEASES Letairis 3961 PULMONARY DISEASES Tyvaso Botox BOTULINUM TOXINS Approval Approved from 06/06/2016 thru 12/06/2016 PULMONARY ARTERIAL HYPERTENSION PULMONARY ARTERIAL HYPERTENSION Approval Approved from 06/06/2016 thru 06/06/2017 Approval Approved from 06/06/2016 thru 06/06/ RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/06/2016 thru 06/06/ RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval Approved from 06/14/2016 thru 06/14/2018 CARDIOLOGY Tikosyn CARDIAC DISORDERS. Tikosyn if the patient does not have a diagnosis of atrial fibrillation or atrial flutter, paroxysmal supraventricular tachycardia (PSVT), or ventricular tachyarrhythmia. Kerry Pierson, R.Ph. Texas Lic# CARDIOLOGY Humira RHEUMATOID ARTHRITIS No Response 2

3 CARDIOLOGY Repatha Approval Approved for 3 months Approved from 04/12/2016 thru 07/12/2016 CARDIOLOGY Humira RHEUMATOID ARTHRITIS No Response DERMATOLOGY Nexavar ONCOLOGY Approval Approved from 04/05/2016 thru 04/05/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS No Response DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/11/2016 thru 04/11/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/2018 DERMATOLOGY Stelara PSORIASIS No Response DERMATOLOGY Stelara PSORIASIS DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Current plan approved criteria does not allow coverage of Stelara if there has not been an inadequate response, intolerance or confirmed adverse event to at least one of the preferred products (Enbrel or Humira), or a contraindication to its use. Phuc Duong, RPh, TX License #33014 Approved from 04/14/2016 thru 04/14/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/15/2016 thru 04/15/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/15/2016 thru 04/15/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/25/2016 thru 04/25/2018 FAMILY PRACTICE Prolia OSTEOPOROSIS Approval Prolia will be approved for 24 months (maximum of 60mg per 6 months). FAMILY PRACTICE Prolia OSTEOPOROSIS Approval Approved from 04/06/2016 thru 04/06/2018 FAMILY PRACTICE Botox BOTULINUM TOXINS Approval Botox approved for 12 months (maximum of 360 Units administered in a 12-week interval). FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS No Response FAMILY PRACTICE Stelara PSORIASIS Approval Approved from 04/11/2016 thru 04/11/2018 FAMILY PRACTICE Repatha No Response FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS No Response FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS No Response FAMILY PRACTICE Repatha Approval Approved from 04/26/2016 thru 07/26/2016 FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS Approval Approved from 04/27/2016 thru 04/27/2018 GASTROENTEROLOGY Simponi RHEUMATOID ARTHRITIS Approval Approved x 24 months GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/04/2016 thru 04/04/2018 Enbrel approved for 24 months with a maximum dose of 50 mg per week. Approved x 24 months with a maximum dose of 240 mg total for the first 15 days and 40 mg per 2 weeks thereafter. GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/2018 3

4 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/14/2016 thru 04/14/2018 HEMATOLOGY & ONCOLOGY Zykadia ONCOLOGY Approval Approved from 04/01/2016 thru 04/01/2017 HEMATOLOGY & ONCOLOGY Lupron Depot HORMONAL THERAPIES Lupron if the patient has not been determined to have a bone mineral density within normal limits. Phuc Duong,RPh, TX License #33014 HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approved from 04/07/2016 thru 04/07/2018 HEMATOLOGY & ONCOLOGY Zytiga ONCOLOGY Approval Zytiga will be approved for 24 months with a maximum dose of max dose 1000 mg/day HEMATOLOGY & ONCOLOGY Procrit ANEMIA No Response HEMATOLOGY & ONCOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/11/2016 thru 04/11/2018 HEMATOLOGY & ONCOLOGY Sutent ONCOLOGY Approval Approved from 04/12/2016 thru 04/12/2018 HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approved from 04/15/2016 thru 04/15/2018 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY HEMATOLOGY & ONCOLOGY Gleevec ONCOLOGY capecitabine if the prescribed regimen for treatment of colorectal cancer is not one of the following: capecitabine monotherapy, capecitabine + bevacizumab (Avastin), capecitabine + bevacizumab + oxaliplatin, capecitabine + oxaliplatin, or capecitabine + radiation therapy. Phuc Duong,RPh, TX License #33014 Gleevec if the patient has not failed treatment with the generic medication, imatinib mesylate, due to an intolerable adverse event (rash, nausea, vomiting). HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 04/22/2016 thru 04/22/2018 HEMATOLOGY & ONCOLOGY Neupogen NEUTROPENIA Approval Approved x 6 months. Approved from 04/22/2016 thru 10/22/2016 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 04/27/2016 thru 04/27/2018 HEMATOLOGY & ONCOLOGY Afinitor ONCOLOGY Approval Approved from 04/29/2016 thru 04/29/2017 INTERNAL MEDICINE Letairis PULMONARY ARTERIAL HYPERTENSION Letairis if the patient does not have a diagnosis of World Health Organization (WHO) group 1 class of pulmonary arterial hypertension confirmed by a pretreatment right heart catheterization with all of the following results: mean pulmonary arterial pressure greater than or equal to 25 mmhg, capillary wedge pressure less than or equal to 15 mmhg, and pulmonary vascular resistance greater than 3 Wood units. Phuc Duong, RPh, TX License #33014 INTERNAL MEDICINE Zytiga ONCOLOGY No Response INTERNAL MEDICINE Zytiga ONCOLOGY Approval Approved from 04/04/2016 thru 04/04/2018 INTERNAL MEDICINE Inlyta ONCOLOGY Approval Approved from 04/06/2016 thru 04/06/2018 INTERNAL MEDICINE Sprycel ONCOLOGY Approval Approved from 04/06/2016 thru 04/06/2017 4

5 INTERNAL MEDICINE Repatha INTERNAL MEDICINE Sutent ONCOLOGY Approval Repatha if the patient has not received a laboratory testing of cholesterol recently (within the last 90 days), if there is no documented trial of Crestor (rosuvastatin) greater than or equal to (?) 20mg plus Zetia (ezetimibe) 10mg together daily, no documented trial of Lipitor (atorvastatin)? 40mg plus Zetia (ezetimibe) 10mg together daily, and no documented contraindication to statins. Kerry Pierson, R.Ph. Texas Lic #24228 Sutent will be approved for 24 months with a max dose of 50 mg/day. INTERNAL MEDICINE Forteo OSTEOPOROSIS No Response INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 04/19/2016 thru 04/19/2018 INTERNAL MEDICINE Cimzia INFLAMMATORY BOWEL DISEASE Approval Approved from 04/20/2016 thru 04/20/2018 MEDICAL ONCOLOGY Afinitor ONCOLOGY Approval Approved x 24 months with a max dose of 10 mg/day. NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE Sensipar if the patient is not currently receiving regular dialysis treatments or post-kidney transplant. -Deborah Claus, RPh, TX License #: NEPHROLOGY / RENAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 04/21/2016 thru 04/21/2018 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 04/01/2016 thru 04/01/2018 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 04/05/2016 thru 04/05/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 04/19/2016 thru 10/04/2016 NEUROLOGY Xolair ASTHMA Approval Approved from 04/22/2016 thru 04/22/2017 NEUROLOGY, PEDIATRIC Repatha Approval Approved for 3 months. Approved from 04/06/2016 thru 07/06/2016. Stelara PSORIASIS Approval Approved from 04/05/2016 thru 04/05/2018 Forteo OSTEOPOROSIS Forteo if clinical reason for avoiding treatment with an oral bisphosphonate is not at least one of the following: esophageal abnormality that delays emptying such as stricture or achalasia, active upper gastrointestinal problem (examples: dysphagia, gastritis, duodenitis, erosive esophagitis, ulcers), inability to stand or sit upright for 30 to 60 minutes, inability to take oral bisphosphonate at least 30 to 60 minutes before first food, drink or medication of the day, or renal insufficiency (creatinine clearance less than 30 ml/min). Phuc Duong,RPh, TX License #33014 Prolia OSTEOPOROSIS Approval Approved from 04/14/2016 thru 04/14/2018 Forteo OSTEOPOROSIS Prolia if there has not been at least a 1-year trial of an oral bisphosphonate and there is no clinical reason to avoid treatment with an oral bisphosphonate. Kerry Pierson, R.Ph. Texas Lic#24228 Thalomid ONCOLOGY Approval Approved from 04/25/2016 thru 04/25/2018 5

6 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES No Response OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Lupron Depot 11.25mg if the patient does not have a diagnosis of breast cancer, endometriosis, fallopian tube cancer, ovarian cancer, primary peritoneal cancer, uterine fibroids, or gender identity disorder (GID). -Deborah Claus, RPh, TX License #: OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 04/29/2016 thru 07/29/2016 PHYSICIAN, ENDOCRINOL- OGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 04/06/2016 thru 04/06/2018 Humira RHEUMATOID ARTHRITIS Approval Approved from 04/11/2016 thru 04/11/2018 Humira RHEUMATOID ARTHRITIS Approval Approved from 04/14/2016 thru 04/14/2018 Stelara PSORIASIS Approval Approved from 04/22/2016 thru 04/22/2018 Norditropin PULMONARY DISEASES Tyvaso PULMONARY ARTERIAL HYPERTENSION Approval Approved from 04/27/2016 thru 04/27/2017 RHEUMATOLOGY Prolia OSTEOPOROSIS RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Tyvaso if the patient does not have a diagnosis of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH). Thao Trinh, Pharm.D, TX License # Prolia if patient has not had at least a 1-year trial of an oral bisphosphonate and there is no clinical reason to avoid treatment with an oral bisphosphonate. Kerry Pierson, R.Ph. Texas LIc #24228 Xeljanz if there is not a clinical reason for not trying both of the preferred drugs (Enbrel, Humira), such as a primary lack of response. Deborah Claus, RPh, TX License #: Approved from 04/04/2016 thru 04/04/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/05/2016 thru 04/05/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/05/2016 thru 04/05/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Cimzia approved for 24 months with a maximum dose of 1200 mg total for the first 28 days and 400 mg per 28 days thereafter. RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/07/2016 thru 04/07/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/07/2016 thru 04/07/2018 RHEUMATOLOGY Vivitrol ALCOHOL DEPENDENCY No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/11/2016 thru 04/11/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response 6

7 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Approval Current plan approved criteria does not allow coverage of Humira unless methotrexate dose has been titrated to greater than or equal to 25 mg per week, patient has an intolerance or contraindication to methotrexate, or the patient has severely active rheumatoid arthritis that warrants a biologic DMARD as first-line therapy. OBC to MDO and LVM for Tanita to inform of Humira denial and appeals info. -Deborah Claus, RPh, TX License #: Approved from 04/15/2016 thru 04/15/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/18/2016 thru 04/18/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Current plan approved criteria does not allow coverage of Cimzia if there has not been an inadequate response, intolerance or confirmed adverse event to at least one of the preferred products (Enbrel or Humira), or a contraindication to its use. Phuc Duong,RPh, TX License #33014 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/19/2016 thru 04/19/2018 RHEUMATOLOGY Stelara PSORIASIS Approval Approved from 04/20/2016 thru 04/20/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/21/2016 thru 04/21/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/21/2016 thru 04/21/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Cimzia if there has not been an inadequate response, intolerance or confirmed adverse event to both of the preferred products (Enbrel and Humira) or a clinical reason for not trying both of the preferred drugs (such as, primary lack of response). Thao Trinh, Pharm.D, TX License # RHEUMATOLOGY Adcirca PULMONARY ARTERIAL HYPERTENSION Adcirca if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred product, sildenafil tablets, or a contraindication to it s use; Raynauds syndrome without gangrene is not an approvable indication. Kerry Pierson, RPH. Texas Lic #24228 ANESTHESIOLOGY Botox BOTULINUM TOXINS Approval Approved from 05/02/2016 thru 10/17/2016 CARDIOLOGY Repatha Repatha unless the patient has documentation (patient?s chart, medical record or laboratory report) indicating creatine kinase (CK) level elevation, rhabdomyolysis, and/or myopathy as an adverse reaction to previous treatment with statin therapy. Thao Trinh, Pharm.D, TX License # CARDIOLOGY Humira RHEUMATOID ARTHRITIS No Response DERMATOLOGY Humira RHEUMATOID ARTHRITIS No Response DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/02/2016 thru 05/02/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/02/2016 thru 05/02/2018 DERMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response 7

8 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 80 mg total for the first 7 days (given on day 1) and 40 mg per 2 weeks thereafter. DERMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/19/2016 thru 05/19/2018 DERMATOLOGY Stelara PSORIASIS Approval Approved from 05/24/2016 thru 05/24/2018 DERMATOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved for 6 months DERMATOLOGY Humira RHEUMATOID ARTHRITIS No Response ENDOCRINOLOGY, PEDIATRIC Lupron Depot HORMONAL THERAPIES Approval Approved from 05/17/2016 thru 05/17/2017 FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS No Response FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS Approval Approved from 05/19/2016 thru 05/19/2018 FAMILY PRACTICE Prolia OSTEOPOROSIS Approval Approved from 05/19/2016 thru 05/19/2018 FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/26/2016 thru 05/26/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/31/2016 thru 05/31/2018 GASTROENTEROLOGY Rebif MULTIPLE SCLEROSIS Approval Approved from 05/03/2016 thru 05/03/2018 GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 05/05/2016 thru 08/05/2016 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/09/2016 thru 05/09/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/12/2016 thru 05/12/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/05/2016 thru 06/05/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/13/2016 thru 05/13/2018 GASTROENTEROLOGY Xeljanz RHEUMATOID ARTHRITIS Approval Approved from 05/18/2016 thru 05/18/2018 GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 05/19/2016 thru 08/19/2016 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/25/2016 thru 05/25/2018 GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/26/2016 thru 05/26/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/27/2016 thru 05/27/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/27/2016 thru 05/27/2017 GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/31/2016 thru 05/31/2018 HEMATOLOGY Revlimid ONCOLOGY Approval Approved from 05/27/2016 thru 05/27/2017 HEMATOLOGY & ONCOLOGY Gleevec ONCOLOGY brand name Gleevec unless the patient failed treatment with the generic medication, imatinib mesylate, due to an intolerable adverse event (example, rash, nausea, vomiting). -Deborah Claus, RPh, TX License #: HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approved from 05/03/2016 thru 05/03/2017 8

9 HEMATOLOGY & ONCOLOGY Tarceva ONCOLOGY Tarceva if the medication is not being used as subsequent therapy following progression on a cytotoxic regimen. Phuc Duong,RPh, TX License #33014 HEMATOLOGY & ONCOLOGY Afinitor ONCOLOGY Approval Approved from 05/11/2016 thru 05/11/2017 HEMATOLOGY & ONCOLOGY Revlimid ONCOLOGY Approval Approved from 05/13/2016 thru 05/13/2017 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 05/16/2016 thru 05/16/2017 HEMATOLOGY & ONCOLOGY Tykerb ONCOLOGY Approval Approved from 05/16/2016 thru 05/16/2018 HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Approved from 05/16/2016 thru 05/16/2017 INTERNAL MEDICINE Botox BOTULINUM TOXINS Approval INTERNAL MEDICINE Votrient ONCOLOGY Approved x 6 months. Approved from 05/06/2016 thru 11/06/2016 Votrient if the patient does not have a diagnosis of renal cell carcinoma, soft tissue sarcoma, uterine sarcoma, thyroid carcinoma, or dermatofibrosarcoma protuberans (DFSP). -Deborah Claus, RPh, TX License #: INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS No Response INTERNAL MEDICINE Xeljanz RHEUMATOID ARTHRITIS Approval Approved from 05/16/2016 thru 05/16/2018 INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 05/19/2016 thru 05/19/2018 INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per week INTERNAL MEDICINE Afinitor ONCOLOGY No Response MEDICAL ONCOLOGY Repatha NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE Approval Current plan approved criteria does not allow coverage of Repatha if the patient does not have a diagnosis of atherosclerotic cardiovascular disease, homozygous familial hypercholesterolemia (FH), or heterozygous FH. Heterozygous FH is defined by one of the following: certain genetic mutations; a total score of more than 8 on the Dutch Lipid Clinic Network Criteria; patient has a total cholesterol greater than 290 mg/dl or low-density lipoprotein (LDL) cholesterol greater than 190 mg/dl, PLUS tendon xanthoma in the patient, a first-degree relative (brother, sister, parent), or a second-degree relative (grandparent, uncle, aunt). Additionally, the patient does not meet one of the following conditions: tried taking Zetia (ezetimibe) 10 mg and Lipitor (atorvastatin) 40 mg or greater for 3 or more months, tried taking Zetia 10 mg and Crestor (rosuvastatin) 20 mg or greater for 3 or more months, has a contraindication to statins and Zetia, experienced intolerable muscle symptoms to at least two statins (including Lipitor or Crestor) and is currently taking Zetia, experienced intolerable muscle symptoms to at least two statins (including Lipitor or Crestor) and is contraindicated to Zetia. The contraindication to Zetia must be specified as a prior hypersensitivity reaction (examples: rash, urticaria, angioedema, anaphylaxis). Lastly, the documentation of a recent laboratory testing of cholesterol was not provided for review. Thao Trinh, Pharm.D, TX License # Sensipar approved for 12 months with a maximum dose of 180 mg per day. 9

10 NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE No Response NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 05/02/2016 thru 05/02/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 05/03/2016 thru 11/03/2016 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 05/05/2016 thru 06/04/2016 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved for 24 months with a maximum dose of 14 mg per day NEUROLOGY Ampyra MULTIPLE SCLEROSIS No Response NEUROLOGY Botox BOTULINUM TOXINS Approval Approve for 6 months (2 injection cycles) (maximum of 400 Units administered in a 12-week interval). NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 05/25/2016 thru 05/25/2017 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 05/25/2016 thru 05/25/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 05/27/2016 thru 05/27/2017 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 06/25/2016 thru 06/25/2017 NEUROLOGY Prolia OSTEOPOROSIS NEUROLOGY Gilenya MULTIPLE SCLEROSIS Vivitrol ALCOHOL DEPENDENCY Approval Repatha Prolia if there is not any of the following clinical reasons to avoid treatment with an oral bisphosphonate: esophageal abnormality that delays emptying such as stricture or achalasia, active upper gastrointestinal problem (examples: dysphagia, erosive esophagitis), inability to stand or sit upright for 30 to 60 minutes, inability to take oral bisphosphonate at least 30 to 60 minutes before first food, drink or medication of the day, or renal insufficiency (creatinine clearance less than 30 ml/min). Phuc Duong,RPh, TX License #33014 Gilenya if a baseline QTc interval less than 500 milliseconds has not been determined prior to initiation of therapy. Phuc Duong,RPh, TX License #33014 pt has not had urine screen for opioids prior to initiation of Vivitrol therapy - JO, Technician 05/11/ :54 PM Approved from 05/12/2016 thru 05/12/2017 Repatha if there no documentation of a laboratory testing of cholesterol within the last 90 days. Phuc Duong,RPh, TX License #33014 Zecuity MIGRAINE Approval Approved from 05/19/2016 thru 06/18/2016 Stelara PSORIASIS Stelara if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred products Enbrel or Humira, or a contraindication to their use. Kerry Pierson, R.Ph. Texas Lic #24228 Zecuity MIGRAINE No Response OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 05/16/2016 thru 11/16/

11 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES PHYSICIAN, ENDOCRINOL- OGY Lupron if bone mineral density has not been determined within normal limits. The denial is effective on 6/11/2016. Phuc Duong,RPh, TX License #33014 Stelara PSORIASIS Approval Approved from 05/10/2016 thru 05/10/2018 Capecitabine ONCOLOGY Approval Approved for 12 months (05/31/2016 thru 05/31/2017) Repatha PULMONARY DISEASES Adcirca RHEUMATOLOGY Repatha RHEUMATOLOGY Repatha PULMONARY ARTERIAL HYPERTENSION Repatha cannot be approved because the patient has no history of clinical atherosclerotic cardiovascular disease (ASCVD) or a cardiovascular event without familial hypercholesterolemia and is neither heterozygous or homozygous with familial hypercholesterolemia (HeFH or HoFH). Kerry Pierson, R.Ph. Texas Lic #24228 Adcirca if there has not been an inadequate response, intolerance, confirmed adverse event or documented contraindication to the preferred product, generic sildenafil. Additionally, the patient does not have a diagnosis of only World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH). Phuc Duong,RPh, TX License # No Response Rcvd signed PA for Repatha. Pending to clinician for review. Repatha without diagnosis of atherosclerotic cardiovascular disease, a genetic or clinical diagnosis of homozygous familial hypercholesterolemia (HoFH), or a definite diagnosis of familial hypercholesterolemia (FH) confirmed by one of the following criteria: an LDL-receptor mutation, familial defective apo B-100, or a PCSK9 gain-of-function mutation; total cholesterol greater than (>) 290 mg/dl or LDL-C greater than (>) 190 mg/dl plus tendon xanthoma in patient, first-degree relative (brother, sister, parent, child) or second-degree relative (grandparent, uncle, aunt); or Dutch Lipid Clinic Network Criteria: Total score greater than 8 (i.e., definite familial hypercholesterolemia). -Deborah Claus, RPh, TX License #: RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/02/2016 thru 05/02/2018 RHEUMATOLOGY Orencia RHEUMATOID ARTHRITIS Approval Approved from 05/02/2016 thru 05/02/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Cimzia if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred products (Enbrel and Humira) or a contraindication to their use. Approved from 05/06/2016 thru 05/06/2018 Approved from 05/06/2016 thru 05/06/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/09/2016 thru 05/09/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/09/2016 thru 05/09/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/09/2016 thru 05/09/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/10/2016 thru 05/10/

12 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Actemra if the patient does not have a diagnosis of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, unicentric Castleman s disease, or multicentric Castleman s disease. Phuc Duong,RPh, TX License#33014 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/11/2016 thru 05/11/2018 RHEUMATOLOGY Procrit ANEMIA Approval Approve for 12 weeks RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/13/2016 thru 05/13/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/13/2016 thru 05/13/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Approved from 05/16/2016 thru 05/16/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 05/16/2016 thru 05/16/2018 RHEUMATOLOGY Benlysta SYSTEMIC LUPUS ERYTHE- MATOSUS Benlysta if the patient is/was not autoantibody-positive prior to initiating therapy. Thao Trinh, Pharm.D, TX License # RHEUMATOLOGY Orencia RHEUMATOID ARTHRITIS Approval Approved from 05/18/2016 thru 05/18/2018 RHEUMATOLOGY Orencia RHEUMATOID ARTHRITIS Approval Approved from 05/23/2016 thru 05/23/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 50 mg per week. RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 05/25/2016 thru 05/25/2018 ANESTHESIOLOGY Botox BOTULINUM TOXINS No Response ANESTHESIOLOGY Vivitrol ALCOHOL DEPENDENCY Approval Approved from 06/21/2016 thru 06/21/2017 CARDIOLOGY Tikosyn CARDIAC DISORDERS Tikosyn if the medication is given in combination with the followings: cimetidine, dolutegravir (Tivicay), hydrochlorothiazide (alone or in combination with other agents), ketoconazole, megestrol, prochlorperazine, trimethoprim (alone or in combination with sulfamethoxazole), verapamil. Phuc Duong,RPh, TX License #33014 CARDIOLOGY Tikosyn CARDIAC DISORDERS Approval Approved from 06/11/2016 thru 06/11/2017 CARDIOLOGY Repatha CARDIOLOGY Repatha DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval No Response Approval Approved from 06/28/2016 thru 06/28/2017 Approve for 24 months with a maximum loading dose of 240 mg total for the first 15 days and 40 mg per week thereafter. DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/19/2016 thru 06/19/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/23/2016 thru 06/23/2018 DERMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response DERMATOLOGY Humira RHEUMATOID ARTHRITIS No Response ENDOCRINOLOGY, PEDIATRIC Capecitabine ONCOLOGY Approval Approved from 06/11/2016 thru 06/11/

13 FAMILY PRACTICE Vivitrol ALCOHOL DEPENDENCY Approval Approved from 06/02/2016 thru 06/02/2017 FAMILY PRACTICE Vivitrol ALCOHOL DEPENDENCY Approval FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved x 12 months. Approved from 06/03/2016 thru 06/03/2017 Approved from 06/09/2016 thru 06/09/2018 FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS Approval Approved from 06/13/2016 thru 06/13/2018 FAMILY PRACTICE Prolia OSTEOPOROSIS Current plan approved criteria does not allow coverage of Prolia if the patient does not meet any of the following criteria: has a history of an osteoporotic vertebral or hip fracture; a pretreatment T-score of less than or equal to -2.5 (for example -3, -4); a pretreatment T-score that is between -2.5 and -1 plus a pretreatment Fracture Risk Assessment Tool (FRAX) score for any major fracture of greater than or equal to 20%; a pretreatment T-score that is between -2.5 and -1 plus a pretreatment FRAX score for any major fracture of less than 20% as well as a pretreatment FRAX score for hip fracture of greater than or equal to 3%. Thao Trinh, Pharm.D, TX License # FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved for 24 months with a max dose od 50mg per week GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/01/2016 thru 06/01/2018 GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/06/2016 thru 06/06/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/07/2016 thru 06/07/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval GASTROENTEROLOGY Cimzia INFLAMMATORY BOWEL DISEASE No Response Approve for 24 months with a maximum dose of 40 mg per 2 weeks. Received clinical documentation from MDO for Cimzia. Pending to clinician for further review - SG, Technician 06/02/ :29 AM GASTROENTEROLOGY Stelara PSORIASIS Approval Approved from 06/17/2016 thru 06/17/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/18/2016 thru 06/18/2018 GASTROENTEROLOGY Simponi RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Serostim GASTROENTEROLOGY Serostim Serostim if the body mass index (BMI), prior to initiating therapy with Serostim, is not less than 18.5 kilograms per square meter. Phuc Duong,RPh, TX License #33014 Approval Approved from 06/20/2016 thru 09/12/2016 GASTROENTEROLOGY Simponi RHEUMATOID ARTHRITIS Approval Approved from 06/20/2016 thru 06/20/2018 GASTROENTEROLOGY Serostim GASTROENTEROLOGY Cimzia INFLAMMATORY BOWEL DISEASE Serostim because the patient s BMI (body mass index) prior to initiating therapy with Serostim is 20.5 kg/m^2. Deborah Claus, RPh, TX License #: Approval Approved from 06/23/2016 thru 06/23/2018 GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/28/2016 thru 06/28/

14 GASTROENTEROLOGY Stelara PSORIASIS Approval Approved from 06/28/2016 thru 06/28/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/28/2016 thru 06/28/2018 GASTROENTEROLOGY Remicade INFLAMMATORY BOWEL DISEASE Approval Approved for 24 months HEMATOLOGY Thalomid ONCOLOGY Approval Approve for 12 months (Max dose 400mg/day) HEMATOLOGY & ONCOLOGY Neupogen NEUTROPENIA Approval Approved for 6 months HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Ibrance if human epidermal growth factor receptor 2 (HER2) status is not negative, and letrozole is not being used as initial endocrine based therapy in the setting of metastatic/ advanced disease. Phuc Duong,RPh, TX License #33014 HEMATOLOGY & ONCOLOGY Tarceva ONCOLOGY Approval Approved from 06/02/2016 thru 06/02/2017 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 06/10/2016 thru 06/10/2017 HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Ibrance if letrozole in combination with Ibrance will not be used as initial endocrine based therapy in the setting of metastatic/advanced disease. Phuc Duong,RPh, TX License #33014 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 06/14/2016 thru 06/14/2017 HEMATOLOGY & ONCOLOGY Temozolomide ONCOLOGY Approval Approved from 06/17/2016 thru 06/17/2018 HEMATOLOGY & ONCOLOGY Revlimid ONCOLOGY Approval Approved from 06/21/2016 thru 06/21/2017 HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approved from 06/29/2016 thru 06/29/2017 INTERNAL MEDICINE Sensipar RENAL DISEASE Approval Approved from 06/02/2016 thru 06/02/2017 INTERNAL MEDICINE Forteo OSTEOPOROSIS No Response INTERNAL MEDICINE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/06/2016 thru 06/06/2018 INTERNAL MEDICINE Zytiga ONCOLOGY Approval Approved from 06/06/2016 thru 06/06/2018 INTERNAL MEDICINE Sprycel ONCOLOGY No Response INTERNAL MEDICINE Sprycel ONCOLOGY Approval Approved from 06/08/2016 thru 06/08/2017 INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 06/08/2016 thru 06/08/2018 INTERNAL MEDICINE Prolia OSTEOPOROSIS Approval Approve for 24 months (Max dose of 60 mg per 6 months). INTERNAL MEDICINE Forteo OSTEOPOROSIS Approval Approved from 06/09/2016 thru 09/09/2016 INTERNAL MEDICINE Intron A ONCOLOGY Intron A if the patient does not have a diagnosis of hepatitis B virus (including hepatitis D co-infection), hepatitis C virus, condylomata acuminata, malignant melanoma, renal cell carcinoma, clinically aggressive follicular non-hodgkins lymphoma, giant cell tumor of the bone, systemic light chain amyloidosis, desmoid tumors, adult T-cell leukemia/lymphoma, hairy cell leukemia, acquired immune deficiency syndrome (AIDS) related Kaposis sarcoma, mycosis fungoides/ Szary syndrome, or polycythemia vera. Phuc Duong,RPh, TX License #

15 INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS No Response INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 06/27/2016 thru 06/27/2018 MEDICAL ONCOLOGY Octreotide Acetate ACROMEGALY Approval Approved from 06/14/2016 thru 06/14/2017 MEDICAL ONCOLOGY Sandostatin ACROMEGALY No Response NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE Approval Approved from 06/14/2016 thru 06/14/2017 Sensipar RENAL DISEASE Approval Approved from 06/14/2016 thru 06/14/2017 Sensipar RENAL DISEASE No Response NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 06/06/2016 thru 06/06/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 06/08/2016 thru 06/08/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 06/11/2016 thru 12/11/2016 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved x 12 months. Approved from 06/15/2016 thru 06/15/2017 NEUROLOGY Rebif MULTIPLE SCLEROSIS Approval Approved from 06/23/2016 thru 06/23/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approve for 6 months (2 injection cycles) (maximum of 400 Units administered in a 12-week interval). NEUROLOGY Aubagio MULTIPLE SCLEROSIS No Response NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 07/30/2016 thru 07/30/2017 NEUROLOGY Enbrel RHEUMATOID ARTHRITIS Approval NURSE PRACTITIONER, ACUTE CARE NURSE PRACTITIONER, ACUTE CARE NURSE PRACTITIONER, ACUTE CARE NURSE PRACTITIONER, ACUTE CARE NURSE PRACTITIONER, PEDI- ATRIC CARE Approved from 06/30/2016 thru 06/30/2018 Pomalyst ONCOLOGY Approval Approved from 06/09/2016 thru 06/09/2017 Humira RHEUMATOID ARTHRITIS No Response Humira RHEUMATOID ARTHRITIS Approval Received signed \incomplete PA form from MDO for Humira. Previous PA on file expires 07/08/16. Answered criteria questions. Question # 5b, Has the patient achieved or maintained positive clinical response to treatment as evidenced, is not answered. Bizfax PA form to MDO for completion. Pending to clinician queue for further review. - SG, Technician 06/20/ :39 PM Approved from 06/28/2016 thru 06/28/2018 Humira RHEUMATOID ARTHRITIS Approval Approved from 06/28/2016 thru 06/28/2018 Botox BOTULINUM TOXINS Approval Approved from 06/30/2016 thru 12/30/2016 Vivitrol ALCOHOL DEPENDENCY Humira RHEUMATOID ARTHRITIS Approval Humira RHEUMATOID ARTHRITIS Approval Vivitrol if the patient has not had a naloxone challenge test or a urine screen for opioids prior to initiation of Vivitrol therapy. Thao Trinh, Pharm.D, TX License # Approved from 06/09/2016 thru 06/09/2017 Approved from 06/09/2016 thru 06/09/2017 Approved from 06/15/2016 thru 06/15/

16 Epogen ANEMIA Approval Approved from 06/16/2016 thru 09/08/2016 Humira RHEUMATOID ARTHRITIS Approval Approved from 07/10/2016 thru 07/10/2018 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 06/14/2016 thru 09/14/2016 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Lupron Depot if the patient has not been determined to have a bone mineral density within normal limits. Deborah Claus, RPh, TX License #: OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 06/30/2016 thru 12/30/2016 ONCOLOGY, GYNECOLOGIC Neupogen NEUTROPENIA Approval Approved from 06/29/2016 thru 12/29/2016 PHYSICIAN, ENDOCRINOL- OGY PHYSICIAN, ONCOLOGY, MEDICAL PHYSICIAN, ONCOLOGY, MEDICAL Humira RHEUMATOID ARTHRITIS Approval Approved from 06/17/2016 thru 06/17/2018 Otezla PSORIASIS Otezla if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred products Enbrel or Humira or a contraindication to their use. Kerry PIerson, R.Ph. Texas Lic #24228 Forteo OSTEOPOROSIS Approval Approved from 06/14/2016 thru 06/14/2018 Tarceva ONCOLOGY Approval Approved from 06/06/2016 thru 06/06/2017 Temozolomide ONCOLOGY Approval Approved from 07/17/2016 thru 07/17/2018 PSYCHIATRY Vivitrol ALCOHOL DEPENDENCY Approval Approved from 06/15/2016 thru 06/15/2017 PULMONARY DISEASES Letairis PULMONARY ARTERIAL HYPERTENSION Letairis if the patient does not have a diagnosis of only World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH). Phuc Duong,RPh, TX License #33014 PULMONARY DISEASES Adcirca PULMONARY ARTERIAL HYPERTENSION Adcirca if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred product sildenafil tablets or a contraindication to its use or to any of its components. Kerry Pierson, R.Ph. Texas Lic #24228 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/01/2016 thru 06/01/2018 RHEUMATOLOGY Letairis PULMONARY ARTERIAL HYPERTENSION RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Approved from 06/02/2016 thru 06/02/2017 Approve for 24 months with a maximum dose of 50 mg per week. Enbrel if the patient does not have a diagnosis of ankylosing spondylitis, axial spondyloarthritis, plaque psoriasis, psoriatic arthritis, polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, rheumatoid arthritis, or reactive arthritis. Kerry Pierson, R.Ph. Texas Lic #24228 Approval Approved from 06/10/2016 thru 06/10/

17 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/10/2016 thru 06/10/2018 RHEUMATOLOGY Repatha Repatha if there is not a documented CK level elevation to support either statin-associated myositis or statin-associated rhabdomyolysis. Thao Trinh, Pharm.D, TX License # RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approve for 24 months with a maximum dose of 40 mg per 2 weeks. Humira if documentation of negative latent tuberculosis (TB) test has not been provided. -Deborah Claus, RPh, TX License #: RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/15/2016 thru 06/15/2018 RHEUMATOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 06/15/2016 thru 12/15/2016 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/15/2016 thru 06/15/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/15/2016 thru 06/15/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/20/2016 thru 06/20/2018 RHEUMATOLOGY Simponi RHEUMATOID ARTHRITIS Approval Approved from 07/17/2016 thru 07/17/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/22/2016 thru 06/22/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 06/23/2016 thru 06/23/2018 RHEUMATOLOGY Repatha Repatha if the patient does not meet one of the following conditions: tried taking Zetia (ezetimibe) 10 mg and Lipitor (atorvastatin) 40 mg or greater for 3 or more months, tried taking Zetia 10 mg and Crestor (rosuvastatin) 20 mg or greater for 3 or more months, has a contraindication to statins and Zetia, experienced intolerable muscle symptoms to at least two statins (including Lipitor or Crestor) and is currently taking Zetia, experienced intolerable muscle symptoms to at least two statins (including Lipitor or Crestor) and is contraindicated to Zetia. The contraindication to Zetia must be specified as a prior hypersensitivity reaction (examples: rash, urticaria, angioedema, anaphylaxis). Thao Trinh, Pharm.D, TX License # RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/24/2016 thru 06/24/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Approved from 06/28/2016 thru 06/28/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved for 12 months; max dose 3.75 mg per month GASTROENTEROLOGY Xeljanz RHEUMATOID ARTHRITIS Approval 3954 MEDICAL ONCOLOGY Xeloda ONCOLOGY Xeljanz approved for 24 months with a maximum dose of 10 mg per day. Xeloda unless the patient is using Xeloda as monotherapy or in combination with lapatinib (Tykerb), docetaxel (Taxotere), ixabepilone (Ixempra), or trastuzumab (Herceptin). Thao Trinh, Pharm.D, TX License # MEDICAL ONCOLOGY Xeloda ONCOLOGY Approval Xeloda approved for 12 months 17

18 3954 NURSE PRACTITIONER, ACUTE CARE Repatha No Response 3954 NURSE PRACTITIONER, ACUTE CARE Repatha Repatha if there is lack of information: it is unknown if the patient has prior history of atherosclerotic cardiovascular disease (ASCVD) or event with or without familial hypercholesterolemia. -Deborah Claus, RPh, TX License #: NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 06/17/2016 thru 06/17/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 06/24/2016 thru 06/24/ RHEUMATOLOGY Otezla PSORIASIS 3952 DERMATOLOGY Otezla PSORIASIS 3952 ENDOCRINOLOGY, PEDIATRIC Humatrope 3952 ENDOCRINOLOGY, PEDIATRIC Norditropin 3952 ENDOCRINOLOGY, PEDIATRIC Norditropin 3952 ENDOCRINOLOGY, PEDIATRIC Norditropin 3952 ENDOCRINOLOGY, PEDIATRIC Humatrope 3952 ENDOCRINOLOGY, PEDIATRIC Humatrope Current plan approved criteria does not allow coverage of Otezla if there has not been an inadequate response, intolerance or confirmed adverse event to either of the preferred products (Enbrel or Humira), or a contraindication to their use. Additionally, there has not been a trial of at least two prior disease-modifying antirheumatic drugs (examples: methotrexate, leflunomide, sulfasalazine, Cimzia, Cosentyx, Enbrel, Humira, Remicade, Simponi, Stelara). Phuc Duong,RPh, TX License #33014 Otezla if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred products, Enbrel or Humira, or a contraindication to their use. Kerry Pierson, R.Ph. Texas Lic #24228 Humatrope if the patient does not have a pretreatment 1-year height velocity greater than 1 standard deviation (SD) below the mean for age and gender. Kerry Pierson, R.Ph. Texas Lic #24228 Norditropin if the pretreatment 1-year height velocity is not greater than 1 standard deviation below the mean for age and gender. Phuc Duong, RPh, TX License #33014 Approval Approved from 04/19/2016 thru 04/19/2017 Norditropin if the patient does not have a pretreatment 1-year height velocity greater than 1 standard deviation (SD) below the mean for age and gender. Thao Trinh, Pharm.D, TX License # No Response Humatrope if the patient does not have any of the following diagnoses: pediatric growth hormone deficiency (includes panhypopituitarism), Turner syndrome, Noonan syndrome, small for gestational age, Prader-Willi syndrome, short stature homeobox (SHOX) deficiency, adult growth hormone deficiency (includes panhypopituitarism), human immunodeficiency virus (HIV) associated wasting, short bowel syndrome, chronic kidney disease, growth failure associated with congenital adrenal hyperplasia, growth failure associated with cerebral palsy, growth failure associated with cystic fibrosis, or growth failure associated with Russell-Silver syndrome. Thao Trinh, Pharm.D, TX License #

19 3952 FAMILY PRACTICE Repatha Current plan approved criteria does not allow coverage of Repatha if clinical documentation of statin-associated rhabdomyolysis is not provided (such as the patient?s chart, medical record or laboratory report). Thao Trinh, Pharm.D, TX License # FAMILY PRACTICE Cosentyx PSORIASIS Approval Approved from 04/27/2016 thru 04/27/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval 3952 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval 3952 HEMATOLOGY & ONCOLOGY Xeloda ONCOLOGY Approved from 04/08/2016 thru 04/08/2018 Approved x 24 months with a max dose of 40 mg per 2 weeks Current plan approved criteria does not allow coverage of Xeloda unless the prescribed regimen is Xeloda alone (monotherapy), Xeloda + bevacizumab (Avastin) + oxaliplatin, Xeloda + bevacizumab (Avastin), Xeloda + oxaliplatin, or Xeloda + radiation therapy. -Deborah Claus, RPh, TX License #: INTERNAL MEDICINE Actemra RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/ INTERNAL MEDICINE Xeloda ONCOLOGY Approval Approved from 04/26/2016 thru 04/26/ NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Ampyra approved for 12 months with a maximum dose of 20 mg per day 3952 NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 05/30/2016 thru 05/30/ Rebif MULTIPLE SCLEROSIS Approval Approved from 04/19/2016 thru 04/19/2018 Zytiga ONCOLOGY Approval Approved from 04/08/2016 thru 04/08/2018 Procrit ANEMIA Approval Approved from 04/19/2016 thru 06/18/2016 Aubagio MULTIPLE SCLEROSIS Approval Approved from 04/04/2016 thru 04/04/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response 3952 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/11/2016 thru 04/11/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/12/2016 thru 04/12/ RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS No Response 3952 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 04/20/2016 thru 04/20/ RHEUMATOLOGY Cosentyx PSORIASIS No Response 3952 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval 3952 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Pend urgent review case to clinician for futher review. - SG, Technician 04/28/ :56 AM Approved from 04/29/2016 thru 04/29/2018 Current plan approved criteria does not allow coverage of Humira if there has not been an inadequate response, intolerance, contraindication, or confirmed adverse event to a trial of phototherapy or pharmacologic treatment with methotrexate, cyclosporine or acitretin. Additionally, the patient does not have severe psoriasis that warrants a biologic disease-modifying antirheumatic drugs (DMARD) as first-line therapy. Phuc Duong,RPh, TX License #