2018 Cigna-HealthSpring Prior Authorization Criteria

Transcription

1 2018 Cigna-HealthSpring Prior Authorization Criteria Drug Name Prior Authorization Type Description Product Group Covered Uses Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Other Criteria Excluded Drug Criteria ABELCET Antifungals, Polyene 6 months B vs D coverage determination ABRAXANE ACETYLCYSTEINE to new starts (B vs D to Abraxane BvsD coverage determination ACITRETIN Acitretin ACTEMRA Actemra and past medication. Use of Actemra is considered medically necessary for the treatment of rheumatoid arthritis (RA) when BOTH of the following criteria are met: 1) inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., Methotrexate (MTX) Azathioprine, gold, Hydroxychloroquine, Penicillamine, Sulfasalazine and 2) failure, contraindication or intolerance to Enbrel or Humira. Use of Actemra will also be considered medically necessary for the treatment of polyarticular juvenile idiopathic arthritis (PJIA), systemic juvenile idiopathic arthritis (SJIA), giant cell arteritis (GCA) and chimeric antigen receptor (CAR) T cell-induced cytokine release syndrome (CRS). B vs D coverage determination required for Actemra IV. ACTIMMUNE to new starts Actimmune ACYCLOVIR SODIUM ADAGEN IMMUNE STIMULANT S ADEMPAS ADEMPAS ADRUCIL AFINITOR to new starts Afinitor and past medication Afinitor is considered medically necessary for the treatment of patients with advanced renal cell carcinoma after failure of treatment with Sutent (sunitinib) OR Nexavar (sorafenib). AFINITOR DISPERZ to new starts Afinitor and past medication Afinitor is considered medically necessary for the treatment of patients with advanced renal cell carcinoma after failure of treatment with Sutent (sunitinib) OR Nexavar (sorafenib). ALBUTEROL SULFATE ALDURAZYME Enzyme Replacement/ Modifiers ALECENSA to new starts ALIMTA to new starts (B vs D to Alimta BvsD coverage determination

2 ALIQOPA to new starts (B vs D to B vs D coverage determination ALORA (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia. ALORA (PDP SECURE and PDP SECURE EXTRA) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. ALOSETRON HYDROCHLORIDE Alosetron Alosetron will not be approved for use in men, as safety and efficacy in men has not been established. ALOXI (Non-formulary for PDP Secure, PDP Secure- Extra) ALUNBRIG to new starts AMBISOME Antifungals, Polyene 6 months B vs D coverage determination AMIFOSTINE AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTES AMINOSYN II AMINOSYN II 8.5%/ELECTROLYTES AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF AMITRIPTYLINE HCL to new starts Tricyclic Antidepressant s.

3 AMPHOTERICIN B Antifungals, Polyene 6 months B vs D coverage determination AMPYRA Ampyra Ampyra is considered medically necessary for patients with multipl sclerosis with medical documentation of impaired walking ability. ANADROL-50 ANDROXY ANABOLIC STEROIDS, ANDROGEN S ANABOLIC STEROIDS, ANDROGEN S APOKYN Apokyn APREPITANT ARALAST NP ARANESP ALBUMIN FREE ARCALYST ARMODAFINIL ARZERRA HEMATOPOI ETICS Arcalyst Nonamphetamine Central Nervous System Agents For initial treatment of anemia, documentation of Hemoglobin less than 10, transferrin saturation greater than 20%, and ferritin levels greater than 100 obtained over the last 3 months. For res, approvals granted if Hemoglobin does not exceed 10-12g/dL or approvals granted if Hemoglobin does not exceed 10-13g/dL for the indication of reduction of allogeneic red cell transfusions in patients undergoing elective, noncardiac, nonvascular surgery. of Cryopyrin Associated Periodic Syndromes (CAPS), 12 years of age including Familial Cold Auto-inflammatory and older Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) and sleep study for the diagnosis of sleep apnea or narcolepsy 6 months B vs D coverage determination B vs D coverage determination ASCOMP/CODEINE Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ASTAGRAF XL ATGAM to new starts (B vs D to to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination B vs D coverage determination

4 AVASTIN to new starts (B vs D to B vs D coverage determination AVITA Dermatologica l retinoids AVONEX PEN (PDP Secure) Immunomodul ators AVONEX (All plans except PDP Secure) Immunomodul ators Patient must have failure, contraindication or intolerance to two of the following: Avonex, Betaseron, Copaxone, Gilenya and Tecfidera before Rebif will be authorized. AVONEX (PDP Secure) Immunomodul ators AVONEX PEN (All plans except PDP Secure) Immunomodul ators Patient must have failure, contraindication or intolerance to two of the following: Avonex, Betaseron, Copaxone, Gilenya and Tecfidera before Rebif will be authorized. AZACITIDINE AZASAN to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination AZATHIOPRINE to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination BANZEL to new starts Banzel BAVENCIO BELEODAQ BENDEKA to new starts (B vs D to to new starts (B vs D to Beleodaq B vs D coverage determination B vs D coverage determination BENLYSTA BENLYSTA The patient must have a positive autoantibody tes (i.e., anti-nuclear antibody [ANA] greater than or equal to 1:80 and/or anti-double-stranded DNA [anti-dsdna] greater than or equal to 30 IU/ml) The patient must be receiving one standard therapy for SLE with any of the following: corticosteroids, hydroxychloroquine, immunosuppressives (cyclophosphamide, azathioprine, mycophenolate, methotrexate, cyclosporine) or nonsteroidal antiinflammatory drugs AND there must be an absence of severe active lupus nephritis or severe active central nervous system lupus before Benlysta is authorized. B vs D coverage determination.

5 BENZTROPINE MESYLATE Benztropine formulary alternatives if two are available or provided clinical rationale why two safer formulary alternatives are not appropriate for the patient. If one (1) safer formulary alternative is available, then that particular medication would need to be documented as tried and failed or clinical rationale provided as to why that one safer formulary alternative is not appropriate for the patient. Safer alternatives depend on indication. For Parkinsonism, safer alternatives are: Carbidopa/Levodopa, Pramipexole, Ropinirole, Bromocriptine, Amantadine, and Selegiline. For extrapyramidal symptoms, a safer alternative is: Amantadine. BESPONSA BETASERON (PDP Secure) to new starts (B vs D to Immunomodul ators B vs D coverage determination BETASERON (All plans except PDP Secure) Immunomodul ators Patient must have failure, contraindication or intolerance to two of the following: Avonex, Betaseron, Copaxone, Gilenya and Tecfidera before Rebif will be authorized. BICNU BLEOMYCIN SULFATE BORTEZOMIB to new starts (B vs D to Velcade BvsD coverage determination BOSULIF to new starts BRAFTOVI to new starts BUDESONIDE BUPHENYL BUPHENYL BUPRENORPHINE HCL Opioid Agonist Antagonist Analgesics Documentation of opioid dependence. Buprenorphin e-1 mo or 6 mo if preg/hypersen sitive to naloxone. Zubsolv, Subox, and bup/nalox-6 mo The use of buprenorphine for maintenance therapy should be limite to patients who have experienced a hypersensitivity reaction to naloxone or require buprenorphine during pregnancy.

6 BUPRENORPHINE HCL/NALOXONE HCL BUSULFAN BUSULFEX Opioid Agonist Antagonist Analgesics Documentation of opioid dependence. Buprenorphin e-1 mo or 6 mo if preg/hypersen sitive to naloxone. Zubsolv, Subox, and bup/nalox-6 mo The use of buprenorphine for maintenance therapy should be limite to patients who have experienced a hypersensitivity reaction to naloxone or require buprenorphine during pregnancy. BUTALBITAL/ACETAMI NOPHEN/CAFFEINE Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ACETAMI NOPHEN/CAFFEINE/CO DEINE Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN/C AFFEINE Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. BUTALBITAL/ASPIRIN/C AFFEINE/CODEINE Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. CABOMETYX to new starts CALQUENCE to new starts

7 CANCIDAS CAPACET CAPRELSA to new starts Antifungals, Superficial and Systemic Butalbital Combinations Caprelsa not appropriate for the patient Onychomyco sis (fingernails For the treatment of tinea versicolor or pityriasis, use of oral ) - 2mo. ketoconazole or a topical antifungal agent is required prior to the Onychomyco use of Itraconazole. For candidiasis infections (unless specified C. sis (toenails) - 3mo. All other indications - glabrata or C. krusei) use of fluconazole is required prior to the use of itraconazole. Safer alternatives are: naproxen sodium and ibuprofen. CARBAGLU CARBAGLU CARBOPLATIN CARMUSTINE CARNITOR CASPOFUNGIN ACETATE Antifungals, Superficial and Systemic Onychomyco sis (fingernails ) - 2mo. Onychomyco sis (toenails) - 3mo. All other indications - 12mo For the treatment of tinea versicolor or pityriasis, use of oral ketoconazole or a topical antifungal agent is required prior to the use of Itraconazole. For candidiasis infections (unless specified C. glabrata or C. krusei) use of fluconazole is required prior to the use of itraconazole. CAYSTON CAYSTON 7 years and older CEREZYME CHORIONIC GONADOTROPIN Hormonal Agents, Gonadotropins CINRYZE Cinryze Patient must have a confirmed diagnosis of HAE. The patient must have a of more than one severe event per month and have failure, contraindication or intolerance to one conventional therapy for HAE prophylaxis such as aminocaproic acid, danazol or tranexamic acid. B vs D coverage determination. CISPLATIN CLADRIBINE CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5%

8 CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 10% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 5%/DEXTROSE 25% CLINIMIX N14G30E CLINIMIX N9G15E CLINISOL SF 15% CLOFARABINE CLOMIPRAMINE HCL to new starts Tricyclic Antidepressant s. COMETRIQ to new starts COPAXONE (PDP Secure) Immunomodul ators COPAXONE (All plans except PDP Secure) Immunomodul ators Patient must have failure, contraindication or intolerance to two of the following: Avonex, Betaseron, Copaxone, Gilenya and Tecfidera before Rebif will be authorized. CORLANOR CORLANOR 1.) Blood pressure less than 90/50 mmhg. 2.) Sick sinus syndrome, sinoatrial block, or 3rd degree AV block, unless a functioning demand pacemaker is present. 3.) Resting heart rate less than 60 bpm prior to treatment. 4.) Pacemaker dependence (heart rate maintained exclusively by the pacemaker)., previous use of a beta-blocker, LVEF, sinus rhythm, resting HR, and blood pressure The patient must have a diagnosis of chronic heart failure with left ventricular ejection fraction less than or equal to 35%, normal sinus rhythm with resting heart rate greater than or equal to 70 beats per minute, and either be on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use. COSMEGEN COTELLIC to new starts CROMOLYN SODIUM CYCLOBENZAPRINE HCL CYCLOPHOSPHAMIDE Skeletal Muscle Relaxants.

9 CYCLOSPORINE to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination CYCLOSPORINE MODIFIED CYRAMZA CYSTARAN to new starts (B vs D to to new starts (B vs D to CYTARABINE CYTARABINE AQUEOUS DACARBAZINE DACTINOMYCIN DALIRESP DAPTOMYCIN DARZALEX DAUNORUBICIN HCL DEXRAZOXANE DEXTROSE 10%/NACL 0.45% DEXTROSE 5% /ELECTROLYTE#48 VIAFLEX DEXTROSE 10% DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/NACL 0.45% DEXTROSE 20% DEXTROSE 25% DEXTROSE 30% DEXTROSE 40% DEXTROSE 5%/LACTATED RINGERS DEXTROSE 50% to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED CYSTARAN Phosphodiester ase Type 4 (PDE4) B vs D coverage determination B vs D coverage determination B vs D coverage determination

10 DIGITEK Digoxin patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is DIGOX Digoxin patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is DIGOXIN Digoxin patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is DIPYRIDAMOLE ( covered on PDP Secure, PDP Secure-Extra) DOCEFREZ DOCETAXEL DOXEPIN HCL DOXORUBICIN HCL DOXORUBICIN HCL LIPOSOME DRONABINOL to new starts Platelet Modifying Agents Tricyclic Antidepressant s Dronabinol. Safer alternatives are: Clopidogrel, Warfarin, Jantoven, and aspririn/dipyridamole. 6 months B vs D coverage determination ELAPRASE Enzyme Replacement/ Modifiers ELIGARD to new starts Pituitary Hormones

11 ELITEK EMEND EMPLICITI to new starts (B vs D to Empliciti and current medication regimen Empliciti is approved with concurrent use of dexamethasone and lenalidomide. B vs D coverage determination. ENBREL Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). ENBREL MINI Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars).

12 ENBREL SURECLICK Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). ENGERIX-B ENVARSUS XR EPCLUSA EPIRUBICIN HCL ERBITUX ERGOLOID MESYLATES to new starts (B vs D to to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED EPCLUSA Antidementia Agents Documentation from the medical record of diagnosis including genotype, current medication regimen, HCV-RNA levels, of previous HCV therapies and presence/absence of cirrhosis. B vs D coverage determination 12 weeks, based on indication and established treatment guidelines For genotype 1, 4, 5 and 6, clinical information must be provided confirming the patient is not a candidate for Harvoni before Epclusa will be authorized. B vs D coverage determination Safer alternatives are: donepezil, galantamine and rivastigmine. ERIVEDGE ERLEADA ERWINAZE to new starts Erivedge Erleada Erleada is approved for use in combination with a gonadotropinreleasing hormone (GnRH) analog or in patients who have had a bilateral orchiectomy.

13 ESBRIET ESBRIET Other known causes of interstitial lung disease e.g., domestic and occupational environmental exposures, connective tissue disease, and drug toxicity. Diagnosis confirmed by 1.) in patients without surgical lung biopsy: Usual interstitial pneumonia (UIP) pattern on high resolution computed tomography (HRCT) is indicative of IPF or 2.) in patients with surgical lung biopsy: The biopsy pattern is diagnostic of IPF or the combination of HRCT and biopsy pattern is indicative of IPF. Esbriet will be used as monotherapy. ESGIC Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. ESTRADIOL (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia. ESTRADIOL (PDP SECURE and PDP SECURE EXTRA) ETHYOL ETOPOSIDE EVOMELA FABRAZYME FARYDAK FASLODEX FENTANYL CITRATE FENTANYL CITRATE ORAL TRANSMUCOSAL Estrogens to new starts EVOMELA (B vs D to to new starts FARYDAK Transmucosal Fentanyl Citrate Documentation from the medical record of diagnosis 16 years of age and older for fentanyl citrate (lozenge/troche). Enrollment in the Transmucosal Immediate- Release Fentanyl (TIRF) REMS Access program Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. B vs D coverage determination Transmucosal fentanyl products will be covered with documentation of breakthrough cancer pain. The patient must be currently receiving and be tolerant to opioid therapy for persistent cancer pain. The patient must be enrolled in the TIRF REMS Access program.

14 FERRIPROX FERRIPROX FIRAZYR Firazyr Patient must have a confirmed diagnosis of HAE. The patient must have a of a moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion). FIRMAGON FLUDARABINE PHOSPHATE FLUOROURACIL FOLOTYN FORTEO FREAMINE HBC 6.9% FREAMINE III FYAVOLV (MAPD plans) Metabolic Bone Disease agents Estrogens 1.) Pediatric patients or young adults with open epiphyses. 2.) History of prior external beam or implant radiation involving the skeleton 1.) Bone mineral density (BMD) by DEXA at hip and spine. 2.) Confirmation of normal serum alkaline phosphatase or provider statement that Paget s disease has been excluded. 3.) Treatment Member has a of at least one osteoporotic fracture while on Bisphosphonate Therapy OR Member has tried and or failed an ora bisphosphonate or SERM OR the member has documented 2 years from intolerance, contraindication, or hypersensitivity to other initiation of osteoporosis therapies. therapy For patients with a T-score less than or equal to -3.5, failure of oral bisphosphonates or SERMs are not required. Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia. FYAVOLV (PDP SECURE and PDP SECURE EXTRA) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. FYCOMPA (Prior Authorization required for PDP SECURE and PDP SECURE EXTRA) to new starts FYCOMPA GAMMAKED GAMUNEX-C GANCICLOVIR GATTEX GATTEX As long as the patient requires parenteral nutrition and/or IV fluids, 3 months up to.

15 GAZYVA GEMCITABINE GEMCITABINE HCL GENGRAF to new starts (B vs D to to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination B vs D coverage determination GENOTROPIN Pituitary Hormones GENOTROPIN MINIQUICK Pituitary Hormones GILENYA Gilenya GILOTRIF to new starts GRANISETRON HCL HALAVEN to new starts (B vs D to Halaven Documentation of prior treatment with an anthracycline and a taxane. Use of Halaven is considered medically necessary for the treatment of patients with metastatic breast cancer who have previously received at least two chemotherapeutic regimens for the treatment o metastatic disease. B vs D coverage determination. HARVONI HARVONI Documentation from the medical record of diagnosis including genotype, HCV RNA viral levels prior to treatment, of previous HCV therapies, and presence/absence of cirrhosis. 12 to 24 weeks based on indication and established treatment guidelines HECORIA HEPATAMINE HEPLISAV-B HERCEPTIN to new starts (B vs D to to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination B vs D coverage determination HETLIOZ HETLIOZ Documentation that patient is totally blind and lacks light perception

16 HUMIRA Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars).

17 HUMIRA PEN Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). HUMIRA PEN-CROHNS DISEASESTARTER Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars).

18 HUMIRA PEN- PSORIASIS STARTER Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). HUMIRA PEN-CD/UC/HS STARTER Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars).

19 HUMIRA PEN-PS/UV STARTER Immune Suppressants and past medication Use of Humira, Enbrel, or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Rheumatoid Arthritis in patients that have tried and failed methotrexate OR at least 2 alternative disease modifying antirheumatic drugs (DMARDs). 2.) Juvenile Rheumatoid Arthritis in patients that have tried and failed at least 2 DMARDs. 3.) Ankylosing Spondylitis in patients that have tried and failed at least 1 non-steroidal anti-inflammatory drug (NSAID), corticosteroid, OR sulfasalazine. 4.) Plaque Psoriasis in patients that have: a.) moderate to severe chronic disease, b.) minimum body surface area (BSA) involvement of greater than or equal to 5% OR involvement of the palms, soles, head, neck or genitalia, AND c.) tried and failed at least 1 topical agent (topical steroid, calcipotriene, or tazarotene) 5.) Psoriatic Arthritis in patients with active disease. In addition, use of Humira or Remicade (including formulary biosimilars) is considered medically necessary for the treatment of: 1.) Moderate to severe Crohn s Disease in patients that have tried and failed at least 2 of the following: immunomodulators, corticosteroids, or aminosalicylates. 2.) Treatment of moderately to severely active ulcerative colitis in patients who have had inadequate response to at least 2 of the following: corticosteroids, sulfasalazine, mesalamine, azathioprine, 6-mercaptopurine. Use of Humira will also be considered medically necessary for the treatment of hidradenitis suppurativa and uveitis. Use of Remicade will also be considered medically necessary for the treatment of fistulizing Crohn's disease. B vs D coverage determination required for Remicade (including formulary biosimilars). HYDROXYPROGESTERO NE CAPROATE SOLUTION HYDROXYPROGESTERO NE CAPROATE IN OIL to new starts (B vs D to HYDROXYP ROGESTERO NE Makena Makena is authorized to reduce the risk of preterm birth when ALL of the following are met 1.) current singleton pregnancy AND 2.) previous singleton spontaneous preterm birth (preterm birth defined as birth from the period of viability through week 36, 6 days gestation) AND 3.) treatment will be initiated between week 16, 0 days and week 20, 6 days of gestation and not continue beyond week 36, 6 days of gestation or time of delivery (whichever occurs first). B vs D coverage determination 21 weeks B vs D coverage determination IBRANCE to new starts ICLUSIG to new starts IDARUBICIN HCL IDHIFA to new starts IFOSFAMIDE ILARIS Ilaris IMATINIB MESYLATE to new starts IMBRUVICA IMFINZI to new starts to new starts (B vs D to B vs D coverage determination

20 IMIPRAMINE HCL IMOVAX RABIES (H.D.C.V.) to new starts Tricyclic Antidepressant s. INCRELEX Insulin-Like Growth Factor. Documentation of lab data reflecting height standard deviation score, basal IGF-1 score, and growth hormone level. Height standard deviation score must be less than or equal to -3.0 AND the basal IGF-1 score must be below the lower limits of normal for the reporting lab AND the patient must have a normal or elevated growth hormone level (excluding patients with growth hormone gene deletion) AND epiphyses must be confirmed as open in patients greater than or equal to 10 years of age. INLYTA to new starts INTRALIPID IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE/ALBUTEROL SULFATE IRESSA to new starts IRINOTECAN IRINOTECAN HCL ISTODAX ISTODAX (OVERFILL) to new starts (B vs D to to new starts (B vs D to Istodax Istodax and past medication and past medication Use of Istodax is considered medically necessary for the treatment of cutaneous T-cell lymphoma in patients that have tried and failed at least 1 prior therapy. B vs D coverage determination. Use of Istodax is considered medically necessary for the treatment of cutaneous T-cell lymphoma in patients that have tried and failed at least 1 prior therapy. B vs D coverage determination. ITRACONAZOLE Antifungals, Superficial and Systemic Onychomyco sis (fingernails ) - 2mo. Onychomyco sis (toenails) - 3mo. All other indications - 12mo For the treatment of tinea versicolor or pityriasis, use of oral ketoconazole or a topical antifungal agent is required prior to the use of Itraconazole. For candidiasis infections (unless specified C. glabrata or C. krusei) use of fluconazole is required prior to the use of itraconazole. IXEMPRA KIT JAKAFI to new starts

21 JEVANTIQUE LO (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia. JEVANTIQUE LO (PDP SECURE and PDP SECURE EXTRA) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. JEVTANA KABIVEN KADCYLA to new starts (B vs D to to new starts (B vs D to Jevtana BvsD coverage determination B vs D coverage determination KALYDECO KALYDECO Patients with cystic fibrosis (CF) who are homozygous for the F508del mutation in the CFTR gene. CF mutation test documenting patient has one mutation in the CFTR gene that is responsive to ivacaftor based on clinical and/or in vitro assay data. KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/ NACL 0.3% KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% KEYTRUDA KINERET to new starts (B vs D to KINERET For RA: 18 years and older B vs D coverage determination Treatment of rheumatoid arthritis (RA) in adults and when the following criteria are met: inadequate response, intolerance, or contraindication to at least one disease-modifying anti-rheumatic drug (DMARD) (i.e., methotrexate (MTX), azathioprine, gold, hydroxychloroquine, penicillamine, sulfasalazine) AND the patient has had failure, contraindication, or intolerance to Enbrel or Humira. KISQALI to new starts

22 KISQALI FEMARA 200 DOSE to new starts KISQALI FEMARA 400 DOSE to new starts KISQALI FEMARA 600 DOSE to new starts KORLYM KORLYM KUVAN Kuvan KYPROLIS LACTATED RINGERS LACTATED RINGERS VIAFLEX LANOXIN ( covered on PDP Secure, PDP Secure- Extra) Digoxin patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is LANOXIN PEDIATRIC Digoxin patient has tried and failed digoxin 0.125mg daily or provided clinical rationale as to why the lower dose is LARTRUVO to new starts (B vs D to B vs D coverage determination LENVIMA 4 MG DAILY DOSE to new starts LENVIMA 12 MG DAILY DOSE to new starts LENVIMA 10 MG DAILY DOSE to new starts LENVIMA 14 MG DAILY DOSE to new starts

23 LENVIMA 18 MG DAILY DOSE to new starts LENVIMA 20 MG DAILY DOSE to new starts LENVIMA 24 MG DAILY DOSE to new starts LENVIMA 8 MG DAILY DOSE to new starts LETAIRIS Letairis LEUKINE Colony stimulating factors. 6 months LEUPROLIDE ACETATE to new starts Pituitary Hormones LIDOCAINE Lidocaine Patch For the FDA-labeled indication of post-herpetic neuralgia, no additional criteria are required to be met. For diabetic neuropathic pain: the patient must have previous use and inadequate response or intolerance to any ONE medication that is FDA-labeled for diabetic peripheral neuropathy, including (but not limited to) duloxetine and Lyrica. For cancer related neuropathic pain (including treatmentrelated neuropathy), no additional criteria are required to be met. LIPOSYN III LONSURF to new starts LONSURF LUMIZYME Lumizyme B vs D coverage determination LUPRON DEPOT (4- MONTH) to new starts Pituitary Hormones LUPRON DEPOT (6- MONTH) to new starts Pituitary Hormones LUPRON DEPOT MG (3-MONTH) Pituitary Hormones LUPRON DEPOT 22.5 MG (3-MONTH) to new starts Pituitary Hormones LUPRON DEPOT 3.75 MG (1-MONTH) Pituitary Hormones

24 LUPRON DEPOT 7.5 MG (1-MONTH) to new starts Pituitary Hormones LUPRON DEPOT-PED (1- MONTH) Pituitary Hormones LUPRON DEPOT-PED (3- MONTH) Pituitary Hormones LYNPARZA to new starts MAGNESIUM SULFATE IN D5W MAGNESIUM SULFATE INJ MAGNESIUM SULFATE IV MAKENA Makena Makena is authorized to reduce the risk of preterm birth when ALL of the following are met 1.) current singleton pregnancy AND 2.) previous singleton spontaneous preterm birth (preterm birth defined as birth from the period of viability through week 36, 6 days gestation) AND 3.) treatment will be initiated between week 16, 0 days and week 20, 6 days of gestation and not continue beyond week 36, 6 days of gestation or time of delivery (whichever occurs first). 21 weeks B vs D coverage determination MARGESIC Butalbital Combinations Safer alternatives are: naproxen sodium and ibuprofen. MEGESTROL ACETATE ORAL SUSP to new starts Megestrol Suspension AND for chachexia/loss of appetite associated with AIDS, the physician has documented that the patient has tried and failed dronabinol or provided clinical rationale as to why that safer formulary alternative is For all other indications, trial of dronabinol is not required. MEGESTROL ACETATE TABS to new starts Megestrol Tabs. MEKINIST to new starts

25 MEKTOVI to new starts MELPHALAN HYDROCHLORIDE MEMANTINE HCL memantine IR/Namenda XR member is greater than 26 years of age. Prior Authorization is 26 or younger. MEMANTINE HYDROCHLORIDE ER memantine IR/Namenda XR member is greater than 26 years of age. Prior Authorization is 26 or younger. MEMANTINE HCL TITRATION PAK memantine IR/Namenda XR member is greater than 26 years of age. Prior Authorization is 26 or younger. MENEST Menest patient has tried and failed one (1) safer formulary alternative or provided clinical rationale why two safer formulary alternative is For palliative therapy of metastatic breast cancer, no trial of a formulary alternative is required. For vasomotor symptoms of menopause, safer alternatives are: SSRIs, venlafaxine, gabapentin, and Femring. For vaginal symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For all other indications, no formulary alternative is required. MENOSTAR (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia.

26 MENOSTAR (PDP SECURE and PDP SECURE EXTRA) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. MESNA METHOCARBAMOL Skeletal Muscle Relaxants. MINIVELLE (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia. MINIVELLE (PDP SECURE and PDP SECURE EXTRA) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, raloxifene, and Prolia. MITOMYCIN MITOXANTRONE HCL MODAFINIL Nonamphetamine Central Nervous System Agents and sleep study for the diagnosis of sleep apnea or narcolepsy MUSTARGEN MYCOPHENOLATE MOFETIL to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination MYCOPHENOLIC ACID DR to new starts (B vs D to IMMUNE SUPPRESSA NTS - TRANSPLAN T RELATED B vs D coverage determination

27 MYLOTARG to new starts (B vs D to B vs D coverage determination NAGLAZYME Enzyme Replacement/ Modifiers NAMENDA XR memantine IR/Namenda XR member is greater than 26 years of age. Prior Authorization is 26 or younger. NAMENDA XR TITRATION PACK memantine IR/Namenda XR member is greater than 26 years of age. Prior Authorization is 26 or younger. NATPARA Natpara NEBUPENT NEPHRAMINE NERLYNX to new starts NEUMEGA Neumega and lab data reflecting platelet count 6 months Neumega is considered medically necessary for patients that have experienced severe thrombocytopenia (platelet count less than or equal to 20,000 mcg/l) from previous chemotherapy OR patients considered to be at high risk for the development of severe thrombocytopenia. B vs D coverage determination. NEXAVAR to new starts NINLARO to new starts Ninlaro and current medication regimen Ninlaro is approved with concurrent use of dexamethasone and lenalidomide. NIPENT NORETHINDRONE ACETATE/ETHINYL ESTRADIOL (MAPD plans) Estrogens Safer alternatives to the estrogen high risk medications depend on the indication. For Hot Flashes, safer alternatives are: Depo- Estradiol, SSRIs, venlafaxine, gabapentin, and Femring. For Vaginal Symptoms of menopause, safer alternatives are: Premarin Cream, Estring, and Femring. For Bone Density, safer alternatives are: alendronate, risedronate, raloxifene, and Prolia.