Essential Health Benefits Standard Specialty PA and QL List July 2016

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Matthew Grant
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1 Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic Pulmonary Arterial Hypertension Central Nervous System Anticonvulsants Depressant Neurotoxins Parkinson's Sleep Disorder Dermatology JUXTAPID (lomitapide) PRALUENT (alirocumab) REPATHA (evolocumab) ADCIRCA (tadalafil) ADEMPAS (riociguat) FLOLAN (epoprostenol) LETAIRIS (ambrisentan) OPSUMIT (macitentan) ORENITRAM (treprostinil diolamine) REMODULIN (treprostinil) REVATIO (sildenafil) Soln REVATIO (sildenafil) Tabs TRACLEER (bosentan) TYVASO (treprostinil) UPTRAVI (selexipag) UPTRAVI (selexipag) Pack VELETRI (epoprostenol) VENTAVIS (iloprost) SABRIL (vigabatrin) pack XYREM (sodium oxybate) BOTOX (onabotulinumtoxina) DYSPORT (abobotulinumtoxina) MYOBLOC (rimabotulinumtoxinb) XEOMIN (incobotulinumtoxina) APOKYN (apomorphine) HETLIOZ (tasimelteon) Alkylating Agents VALCHLOR (mechlorethamine) Gel Electrolyte & Renal Agents 2 syringes/28 days 3 syringes/28 days 3 tabs/day Updated 07/01/2016 Page 1 of 6 3 tabs/day 1 ampule/day 2 packs/year 9 ampules/day 3 bottles (540 ml)/30 days 20 cartridges/30 days 1 cap/day Diuretics KEVEYIS (dichlorphenamide) 4 tabs/day Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days 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 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 kit/365 days

2 Endocrinology & Metabolism Gonadotropins Growth Hormones and Related Therapy Hormone Modifiers Osteoporosis Somatostatins Enzyme-Related Alpha-1 proteinase inhibitor Cystine-depleting Agents Enzyme Replacement Enzyme, Gout Phenylketonuria Treatment Agents Gastroenterology TRELSTAR (triptorelin) 22.5 mg (6-month) TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) TRELSTAR LA (triptorelin) mg (3-month) VANTAS (histrelin) EGRIFTA (tesamorelin) 1 mg EGRIFTA (tesamorelin) 2 mg NORDITROPIN (somatropin) NUTROPIN (somatropin) NUTROPIN AQ (somatropin) SEROSTIM (somatropin) ZORBTIVE (somatropin) INCRELEX (mecasermin) SOMAVERT (pegvisomant) MYALEPT (metreleptin) H.P. ACTHAR (corticotropin) PROLIA (denosumab) SANDOSTATIN (octreotide) SANDOSTATIN LAR (octreotide) SIGNIFOR (pasireotide) SOMATULINE DEPOT (lanreotide) ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor) CYSTARAN (cysteamine) PROCYSBI (cysteamine bitartrate) ALDURAZYME (laronidase) CEREZYME (imiglucerase) ELAPRASE (idursulfase) ELELYSO (taliglucerase) FABRAZYME (agalsidase beta) KANUMA (sebelipase alfa) LUMIZYME (alglucosidase alfa) MYOZYME (alglucosidase alfa) NAGLAZYME (galsulfase) RAVICTI (glycerol phenylbutyrate) STRENSIQ (asfotase alfa) VIMIZIM (elosulfase) VPRIV (velaglucerase) ZAVESCA (miglustat) KRYSTEXXA (pegloticase) KUVAN (sapropterin) Short Bowel Syndrome GATTEX (teduglutide) 1 injection/168 days 1 injection/28 days 1 injection/84 days 1 implant/year 2 vials (1 mg each)/day 1 vial (2 mg each)/day 2 syringes/year 2 ampules/day 4 bottles/28 days Updated 07/01/2016 Page 2 of 6

3 Immunology Hematopoietic Agents Hepatitis C Agents Immune Globulins Immunomodulators Interleukins Multiple Sclerosis ARANESP (darbepoetin alfa) EPOGEN (epoetin alfa) LEUKINE (sargramostim) MOZOBIL (plerixafor) NEULASTA (pegfilgrastim) NEUMEGA (oprelvekin) NEUPOGEN (filgrastim) NPLATE (romiplostim) PROCRIT (epoetin alfa) PROMACTA (eltrombopag) SOLIRIS (eculizumab) DAKLINZA (daclatasvir dihydrochloride) DAKLINZA (daclatasvir dihydrochloride) 30 mg HARVONI (ledipasvir-sofosbuvir) PEGASYS (peginterferon alfa-2a) PEG-INTRON (peginterferon alfa-2b) SOVALDI (sofosbuvir) ZEPATIER (elbasvir-grazoprevir) 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) OCTAGAM (immune globulin) PRIVIGEN (immune globulin) CIMZIA (certolizumab) ENBREL (etanercept) HUMIRA (adalimumab) KINERET (anakinra) ORENCIA (abatacept) REMICADE (infliximab) SIMPONI (golimumab) SIMPONI ARIA (golimumab) ARCALYST (rilonacept) ILARIS (canakinumab) BENLYSTA (belimumab) AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) BETASERON (interferon beta-1b) COPAXONE (glatiramer) 8 vials (9.6 ml) per transplant 3 tabs/day 2 vials/4 weeks 1 kit (4 syringes)/28 days 1 package/28 days 1 kit/30 days Updated 07/01/2016 Page 3 of 6

4 Immunology Multiple Sclerosis Transplant Collagenase Diagnostic Movement Disorder Agents Toxicology Viscosupplements Obstetrics & Gynecology GILENYA (fingolimod) GLATOPA (glatiramer) SOSY 20 mg/ml LEMTRADA (alemtuzumab) NOVANTRONE (mitoxantrone) REBIF (interferon beta-1a) REBIF (interferon beta-1a) Starter Pack TECFIDERA (dimethyl fumarate) TECFIDERA (dimethyl fumarate) Starter Pack TYSABRI (natalizumab) NULOJIX (belatacept) ZORTRESS (everolimus) XIAFLEX (collagenase clostridium histolyticum) THYROGEN (thyrotropin alfa) XENAZINE (tetrabenazine) EXJADE (deferasirox) FERRIPROX (deferiprone) Tabs JADENU (deferasirox) MONOVISC (hyaluronan) ORTHOVISC (sodium hyaluronate) SYNVISC (sodium hyaluronate) SYNVISC-ONE (sodium hyaluronate) Hormone Replacement MAKENA (hydroxyprogesterone caproate) Oncology (Injectable) Antimicrotubular Interferons Kinase and Molecular Target Inhibitors Monoclonal Antibody HALAVEN (eribulin) JEVTANA (cabazitaxel) INTRON A (interferon alfa-2b) SYLATRON (peginterferon alfa-2b) KYPROLIS (carfilzomib) PORTRAZZA (necitumumab) Soln VELCADE (bortezomib) ZALTRAP (ziv-aflibercept) DACOGEN (decitabine) ISTODAX (romidepsin) SYNRIBO (omacetaxine) ADCETRIS (brentuximab) ARZERRA (ofatumumab) BLINCYTO (blinatumomab) DARZALEX (daratumumab) Soln EMPLICITI (elotuzumab) Solr GAZYVA (obinutuzumab) HERCEPTIN (trastuzumab) KADCYLA (ado-trastuzumab emtansine) OPDIVO (nivolumab) 1 cap/day 1 kit/30 days 12 syringes/28 days 1 starter pack/year 2 caps/day 1 starter pack/year 1 injection /28 days 2 vials/21 days Updated 07/01/2016 Page 4 of 6

5 Oncology (Injectable) PERJETA (pertuzumab) RITUXAN (rituximab) XGEVA (denosumab) YERVOY (ipilimumab) Oncology (Oral) Alkylating Agents Antiandrogen Kinase and Molecular Target Inhibitors TEMODAR (temozolomide) XTANDI (enzalutamide ) ZYTIGA (abiraterone) AFINITOR (everolimus) AFINITOR DISPERZ (everolimus) BOSULIF (bosutinib) CAPRELSA (vandetanib) 100 mg CAPRELSA (vandetanib) 300 mg COMETRIQ (carbozantinib) COTELLIC (cobimetnib) 63 tabs/28 days ERIVEDGE (vismodegib) FARYDAK (panobinostat) 6 caps/ 21 days GILOTRIF (afatinib) GLEEVEC (imatinib) IBRANCE (palbociclib) ICLUSIG (ponatinib) 15 mg ICLUSIG (ponatinib) 45 mg IMBRUVICA (ibrutinib) INLYTA (axitinib) JAKAFI (ruxolitinib) JAKAFI (ruxolitinib) 10 mg LENVIMA (lenvatinib) LYNPARZA (olaparib) MEKINIST (trametinib) NEXAVAR (sorafenib) NINLARO (ixazomib) SPRYCEL (dasatinib) 3 caps/28 days STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TAGRISSO (osimertinib) TARCEVA (erlotinib) TASIGNA (nilotinib) 3 tabs/day TYKERB (lapatinib) VOTRIENT (pazopanib) XALKORI (crizotinib) ZELBORAF (vemurafenib) ZYDELIG (idelalisib) ZYKADIA (ceritinib) LONSURF (trifluridine-tipiracil) MG 100 tabs/28 days Updated 07/01/2016 Page 5 of 6

6 Oncology (Oral) LONSURF (trifluridine-tipiracil) MG TARGRETIN (bexarotene) caps 80 tabs/28 days TARGRETIN (bexarotene) Gel XELODA (capecitabine) ZOLINZA (vorinostat) Thalidomide-related Agents POMALYST (pomalidomide) REVLIMID (lenalidomide) THALOMID (thalidomide) Respiratory Asthma/COPD NUCALA (mepolizumab) 1 vial/28 days XOLAIR (omalizumab) Cystic fibrosis CAYSTON (aztreonam) KALYDECO (ivacaftor) KALYDECO (ivacaftor) Packs PULMOZYME (dornase alfa) Pulmonary Fibrosis ESBRIET (pirfenidone) OFEV (nintedanib) Respiratory Syncytial Virus Agents SYNAGIS (palivizumab) Quantity Limit Programs Therapeutic Category Drug Name Dispensing Limit Anti-infectives Antiretrovirals, Hepatitis B Antiretrovirals, HIV Cardiology BARACLUDE (entecavir) BARACLUDE (entecavir) Soln FUZEON (enfuvirtide) 630 ml/30days 60 vials or 1 kit/30 days Anticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 days Endocrinology & Metabolism Gonadotropins Vasopressin Antagonist Obstetrics & Gynecology FRAGMIN (dalteparin) LOVENOX (enoxaparin) ZOLADEX (goserelin) 10.8 mg ZOLADEX (goserelin) 3.6 mg SAMSCA (tolvaptan) 35 days supply/180 days 35 days supply/180 days 1 injection/84 days 1 injection/28 days 30 days supply/60 days Hormone Replacement CRINONE (progesterone) 8% 60 applicators/30 days Respiratory Cystic fibrosis TOBI PODHALER (tobramycin) 1 package (224 tabs)/56 days 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. *Quantity limits are built into the PA criteria approval and varies based on indication and/or other clinical factors. Updated 07/01/2016 Page 6 of 6

Specialty Pharmacy Drug List - Medical Code Drug Name Generic Name Benefit J9264 Abraxane paclitaxel Medical J3262 Actemra/tocilizumab Anti-inflammatory Medical C9287 Adcetris brentuximab vedotin

7 Specialty Pharmacy Drug List - Medical Code Drug Name Generic Name Benefit J9264 Abraxane paclitaxel Medical J3262 Actemra/tocilizumab Anti-inflammatory Medical C9287 Adcetris brentuximab vedotin Medical J1931 ALDURAZYME/laronidase Enzymes Medical J9305 Alimta pemetrexed Medical J2469 Aloxi palonosetron Medical J0256 Aralast* Alpha-1 Medical J9035 Avastin bevacizumab Medical J1556 BIVIGAM IVIG/immunizing Medical J0585 Botox A onabotulinum toxin toxin A Medical J0586 Botox A (Dysport) abobotulinum toxin A Medical J0588 Botox A (Xeomin) incobotulinum toxin A Medical J0587 Botox B (Myobloc) rimabotulinum toxin B Medical J1566 CARIMUNE IVIG/immunizing Medical J0205 CEREDASE/alglucerase Enzymes Medical J1786 CEREZYME/imiglucerase Enzymes Medical J1743 ELAPRASE/idursulfase Enzymes Medical J9055 Erbitux cetuximab Medical J7323 Euflexxa Medical J0180 FABRAZYME/agalsidase Enzymes Medical

8 J1572 FLEBOGAMMA IVIG/immunizing Medical J0641 Fusilev levoleucovorin Medical J1460 GAMASTAN S/D IVIG/immunizing Medical J1569 GAMMAGARD LIQUID IVIG/immunizing Medical J1566 GAMMAGARD S/D IVIG/immunizing Medical J1561 GAMMAKED IVIG/immunizing Medical J1557 GAMMAPLEX IVIG/immunizing Medical J1561 GAMUNEX IVIG/immunizing Medical J1561 GAMUNEX C IVIG/immunizing Medical J7326 Gel One Medical J0256 Glassia* Alpha-1 Medical J9179 Halaven eribulin mesylate Medical J9355 Herceptin trastuzumab Medical J1559 HIZENTRA IVIG/immunizing Medical J0800 HP Acthar repository corticotropin Medical J7321 Hyalgan Medical J9043 Jevtana cabazitaxel Medical J9354 Kadcyla adotrastuzumab Medical J0221 LUMIZYME/alglucosidase Enzymes Medical J0220 MYOZYME//aglucosiderase Enzymes Medical J1458 NAGLAZYME/galsulfase Enzymes Medical J1568 OCTAGAM IVIG/immunizing Medical J0129 Orencia/abatacept Anti-inflammatory Medical J7324 Orthovisc Medical C9292 Perjeta pertuzumab Medical J1459 PRIVIGEN IVIG/immunizing Medical Q2043 Provenge sipuleucel-t Medical J1745 Remicade/infliximab Anti-inflammatory Medical J9310 Rituxan rituximab Medical J1602 Simponi/golimumab Anti-inflammatory Medical J3357 Stelara/ustekinumab Anti-inflammatory Medical

9 J7321 Supartz Medical J7325 Synvisc One Medical J7325 Synvisc/Hylan Medical J2323 Tysabri Anti-inflammatory Medical J9303 Vectibix Panitumumab Medical J1562 Vivaglobin Medical J3385 VPRIV/Velaglucerase Alfa Enzymes Medical J2357 Xolair omalizumab Medical J9228 Yervoy ipilimumab Medical J0256 Zemaira*/alpha 1 proteinase Alpha-1 Medical

Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015

Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015 J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,