Specialty Overview by Prior Authorization Approval or Denial 4th Quarter 2016

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1 Specialty Overview by Prior Authorization Approval or 4th Quarter 2016 Carrier Physician Specialty Drug Drug Class Decision Comments Reporting Year Reporting Month 3961 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/17/2016 thru 10/17/ MEDICAL ONCOLOGY Ibrance ONCOLOGY Approval Approved from 10/21/2016 thru 10/21/ NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 10/06/2016 thru 10/06/ PEDIATRICS Humatrope Humira if the patient s adult height prediction (5feet, 8 inches) exceeds the approvable 5 feet, 3 inches for boys. Kerry Pierson, R.Ph. Texas Lic # RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/04/2016 thru 10/04/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response 3961 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/20/2016 thru 10/20/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/21/2016 thru 10/21/ HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 11/22/2016 thru 11/22/ Humira RHEUMATOID ARTHRITIS Approval Humira is approve for 24 months with a maximum loading dose of 240 mg total for the first 15 days and 40 mg per week thereafter PSYCHIATRY Vivitrol ALCOHOL DEPENDENCY No Response 3961 PSYCHIATRY Vivitrol ALCOHOL DEPENDENCY Approval Approved from 11/01/2016 thru 11/01/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/05/2016 thru 11/05/ RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/11/2016 thru 11/11/ RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval Approved from 11/21/2016 thru 11/21/ ALLERGY & IMMUNOLOGY Firazyr HEREDITARY ANGIOEDEMA No Response 3961 ALLERGY & IMMUNOLOGY Firazyr HEREDITARY ANGIOEDEMA Approval Firazyr meets guidelines and it is approve for a lifetime. 14day TAT ends 12/29/16. - JT, Pharmacist 12/16/:01 AM 3961 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/19/2016 thru 12/19/ ENDOCRINOLOGY, PEDIATRIC Norditropin 3961 ENDOCRINOLOGY, PEDIATRIC Norditropin 3961 HEMATOLOGY & ONCOLOGY Promacta IMMUNE (IDIOPATHIC) THROMBOCYTOPENIC PURPURA No Response Approval Approved x 12 months. Approved from 01/07/2017 thru 01/07/2018 Approval Approved from 01/15/2017 thru 01/15/2018 1

2 3961 INTERNAL MEDICINE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/19/2016 thru 12/19/ Ampyra MULTIPLE SCLEROSIS Approval Approved from 12/05/2016 thru 12/05/ PULMONARY DISEASES Orkambi CYSTIC FIBROSIS Approval Reviewed verbal and attachment for Orkambi. Dx is CF. Continuation of therapy. Genetic mutation is F508del, pt is homozygous, labs are attached. Will not be used Kalydeco. Orkambi will be approve indefinitely. 14 day tat; 12/20. - JT, Pharmacist 12/06/:29 AM 3961 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response 3961 RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS No Response 3961 RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Approval Approved for 24 months. Approved from 12/28/2016 thru 12/28/2018 DERMATOLOGY Stelara PSORIASIS Approval Approved from 10/03/2016 thru 10/03/2018 DERMATOLOGY Stelara PSORIASIS Approval Approved from 10/04/2016 thru 10/04/2018 DERMATOLOGY Botox BOTULINUM TOXINS Approval Approved from 10/04/2016 thru 10/04/2017 DERMATOLOGY Stelara PSORIASIS Approval Approved from 10/04/2016 thru 10/04/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/17/2016 thru 10/17/2018 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 Stelara PSORIASIS Approval Approved from 10/25/2016 thru 10/25/2018 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. FAMILY PRACTICE Vivitrol ALCOHOL DEPENDENCY Approval Approved from 10/07/2016 thru 10/07/2017 FAMILY PRACTICE Vivitrol ALCOHOL DEPENDENCY No Response FAMILY PRACTICE Stelara PSORIASIS Approval Approved from 10/12/2016 thru 10/12/2018 FAMILY PRACTICE Vivitrol ALCOHOL DEPENDENCY Approval Approved from 10/17/2016 thru 10/17/2017 GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS GASTROENTEROLOGY Remicade GASTROENTEROLOGY Remicade INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE 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). Kerry Pierson, R.Ph. Texas Lic # Current plan approved criteria does not allow coverage of Humira if the patient has not undergone pre-treatment screening for latent tuberculosis (TB) infection with either a TB skin test or an interferon gamma release assay (examples, QFT-GIT, T-SPOT.TB) or the test result is unknown. Deborah Claus, RPh, TX License #: Approval Approved from 10/11/2016 thru 10/11/2018 Approval Approved from 10/17/2016 thru 10/17/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/18/2016 thru 10/18/2018 2

3 GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 10/20/2016 thru 01/20/2017 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/21/2016 thru 10/21/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Lupron Depot 3.75mg if the patient has not been determined to have a bone mineral density within normal limits. Kerry Pierson, R.Ph. Texas Lic#24228 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/24/2016 thru 10/24/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months a maximum dose of 240 mg total for the first 15 days and 40 mg per 2 weeks thereafter. GASTROENTEROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 10/26/2016 thru 11/25/2016 HEMATOLOGY & ONCOLOGY Afinitor ONCOLOGY Afinitor if the patient does not have a diagnosis of renal cell carcinoma, thymomas and thymic carcinomas, classical Hodgkin lymphoma, soft tissue sarcoma, advanced breast cancer, subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis complex (TSC), renal angiomyolipoma associated with tuberous sclerosis complex (TSC), pancreatic neuroendocrine tumor, gastrointestinal neuroendocrine tumor, or Waldenstrm s macroglobulinemia/ lymphoplasmacytic lymphoma. Kerry Pierson, R.Ph. Texas Lic #24228 INTERNAL MEDICINE Forteo OSTEOPOROSIS No Response INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Humira if the patient has not experienced an inadequate response after at least 3 months of treatment with methotrexate at a dose of greater than or equal to 25 mg per week and does not have an intolerance or contraindication to methotrexate therapy. The contraindication to methotrexate must be one of the following: history of intolerance or adverse event; alcoholism, alcoholic liver disease or other chronic liver disease; elevated liver transaminases; interstitial pneumonitis or clinically significant pulmonary fibrosis; renal impairment; pregnancy or planning pregnancy (female or male patient); breastfeeding (female patient); blood dyscrasias (for example: thrombocytopenia, leukopenia, significant anemia); myelodysplasia; hypersensitivity; or significant drug interaction. Thao Trinh, Pharm.D, TX License # INTERNAL MEDICINE Stivarga ONCOLOGY Approval Approved from 10/04/2016 thru 10/04/2017 INTERNAL MEDICINE Tyvaso INTERNAL MEDICINE Humatrope PULMONARY ARTERIAL HYPERTENSION No Response Approval Approved from 10/05/2016 thru 10/05/2017 INTERNAL MEDICINE Humira RHEUMATOID ARTHRITIS Approval Approved from 10/12/2016 thru 10/12/2018 INTERNAL MEDICINE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/14/2016 thru 10/14/2018 3

4 MEDICAL ONCOLOGY Capecitabine ONCOLOGY NEPHROLOGY / RENAL MEDICINE Current plan approved criteria does not allow coverage of capecitabine if the patient does not have a diagnosis of colorectal cancer, breast cancer, esophageal and esophagogastric junction cancer, gastric cancer, gallbladder cancer, intrahepatic cholangiocarcinoma, pancreatic neuroendocrine tumor (PNET) (islet cell tumors), ovarian cancer - epithelial ovarian cancer/fallopian tube, cancer/primary peritoneal cancer, pancreatic adenocarcinoma, central nervous system (CNS) metastases from breast cancer, penile cancer, occult primary cancer, head and neck cancer, renal cell carcinoma (RCC), lung neuroendocrine tumor (LNET), or anal cancer. Kerry Pierson, R.Ph. Texas LIc #24228 Sensipar RENAL DISEASE Approval Approved from 10/21/2016 thru 10/21/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 10/03/2016 thru 10/03/2017 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 10/04/2016 thru 10/04/2018 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Current plan approved criteria does not allow coverage of Aubagio if the patient does not have a diagnosis of relapsing-remitting multiple sclerosis, progressive-relapsing multiple sclerosis, or secondary progressive multiple sclerosis (with documented relapses). Kerry Pierson, R.Ph. Texas Lic #24228 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 10/11/2016 thru 10/11/2018 NEUROLOGY Sensipar RENAL DISEASE Approval Approved from 10/19/2016 thru 10/19/2017 NEUROLOGY, PEDIATRIC Repatha LIPID DISORDERS - PCSK9 INHIBITORS No Response Botox BOTULINUM TOXINS Approval Approved from 10/06/2016 thru 04/06/2017 Neulasta NEUTROPENIA Approval Approved from 10/28/2016 thru 04/28/2017 Capecitabine ONCOLOGY Current plan approved criteria does not allow coverage of capecitabine if the patient does not have a diagnosis of colorectal cancer, breast cancer, esophageal and esophagogastric junction cancer, gastric cancer, gallbladder cancer, intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, pancreatic neuroendocrine tumor (PNET) (islet cell tumors), ovarian cancer - epithelial ovarian cancer/fallopian tube cancer/primary peritoneal cancer, pancreatic adenocarcinoma, central nervous system (CNS) metastases from breast cancer, penile cancer, occult primary cancer, head and neck cancer, renal cell carcinoma (RCC), lung neuroendocrine tumor (LNET), or anal cancer. Kerry Pierson, R.Ph. Texas lic#24228 Epogen ANEMIA Approval Approved from 11/10/2016 thru 02/02/2017 Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/27/2016 thru 10/27/2018 OBSTETRICS & GYNECOLOGY Prolia OSTEOPOROSIS Approval Approved from 10/11/2016 thru 10/11/2018 OBSTETRICS & GYNECOLOGY Prolia OSTEOPOROSIS Approval Approved from 10/11/2016 thru 10/11/2018 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 10/30/2016 thru 04/30/2017 4

5 PHYSICIAN, ENDOCRINOL- OGY PHYSICIAN, PHYSICAL MED- ICINE & REHABILITATION / PHYSIATRY PULMONARY DISEASES Letairis Humira RHEUMATOID ARTHRITIS No Response Humira RHEUMATOID ARTHRITIS Approval Approved from 10/10/2016 thru 10/10/2018 Vivitrol ALCOHOL DEPENDENCY Approval Approved from 10/11/2016 thru 10/11/2017 Ampyra MULTIPLE SCLEROSIS Approval Approved from 10/17/2016 thru 11/16/2016 Stelara PSORIASIS 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 Zoledronic Acid OSTEOPOROSIS Approval Approved from 10/20/2016 thru 10/20/2018 Botox BOTULINUM TOXINS Approval Approved from 10/11/2016 thru 10/11/2017 PULMONARY ARTERIAL HYPERTENSION PULMONARY DISEASES Ibrance ONCOLOGY PULMONARY DISEASES Adcirca PULMONARY ARTERIAL HYPERTENSION Approval Approved from 11/01/2016 thru 11/01/2017 Ibrance + letrozole if the letrozole is not being used as initial endocrine based therapy in the setting of metastatic/advanced disease. Kerry Pierson, R.Ph. Texas Lic #24228 Adcirca if there has not been an inadequate response to a trial of at least a 30-day treatment with generic sildenafil, a documented intolerance or confirmed adverse event to generic sildenafil, or a documented contraindication to generic sildenafil or any of its components. Thao Trinh, Pharm.D, TX License # RHEUMATOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 10/04/2016 thru 01/04/2017 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/05/2016 thru 10/05/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/06/2016 thru 10/06/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/06/2016 thru 10/06/2018 RHEUMATOLOGY Repatha LIPID DISORDERS - PCSK9 INHIBITORS RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Simponi RHEUMATOID ARTHRITIS Approval Repatha if the patient has not received laboratory testing of cholesterol within the last 90 days. The patient has no documented trial of Crestor (rosuvastatin) greater than or equal to 20 mg plus Zetia (ezetimibe) 10 mg together daily nor a documented trial of Lipitor (atorvastatin) greater than or equal to 40 mg plus Zetia (ezetimibe) 10 mg together daily. Finally, the patient has not experienced statin-associated myositis nor statin-associated rhabdomyolysis. Kerry Pierson, R.Ph. Texas Lic #24228 Approved x 24 months. Approved from 10/11/2016 thru 10/11/2018 Approve for 24 months with a maximum dose of 50 mg per 28 days. RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/13/2016 thru 10/13/2018 5

6 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/18/2016 thru 10/18/2018 RHEUMATOLOGY Lupron Depot HORMONAL THERAPIES Lupron Depot 7.5mg if the patient does not have a diagnosis of prostate cancer or gender dysphoria. Kerry Pierson, R.Ph. Texas Lic #24228 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Current plan approved criteria do not allow coverage of Humira if there is missing clinical information including but not limited to: the completed prior authorization form. Thao Trinh, Pharm.D, TX License # Approve for 24 months with a maximum dose of 50 mg per week. RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/31/2016 thru 10/31/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS ANESTHESIOLOGY Vivitrol ALCOHOL DEPENDENCY Approval Humira for psoriatic arthritis if the patient has not experienced an intolerance to, contraindication to, or inadequate response after at least 3 months of treatment with methotrexate, sulfasalazine, or leflunomide and the patient does not have any of the following conditions: active enthesitis, active dactylitis (sausage digit), or predominant axial disease (extensive spinal involvement). Thao Trinh, Pharm.D, TX License # Approved for 12 months. Approved from 11/30/2016 thru 11/30/2017 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/01/2016 thru 11/01/2018 DERMATOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 11/03/2016 thru 01/03/2017 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks. DERMATOLOGY Stelara PSORIASIS Approval Approved from 11/23/2016 thru 11/23/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks. ENDOCRINOLOGY, PEDIATRIC Capecitabine ONCOLOGY Approval Approved from 11/23/2016 thru 11/23/2017 FAMILY PRACTICE Forteo OSTEOPOROSIS Approval Approved from 11/07/2016 thru 11/07/2018 FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/04/2016 thru 12/04/2018 FAMILY PRACTICE Botox BOTULINUM TOXINS Approval Approve for 6 months (2 injection cycles) (maximum of 400 Units administered in a 12-week interval). FAMILY PRACTICE Forteo OSTEOPOROSIS Approval Approved from 11/21/2016 thru 05/21/2018 GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/26/2016 thru 11/26/2018 GASTROENTEROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 11/26/2016 thru 12/26/2016 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/04/2016 thru 11/04/2018 GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 11/05/2016 thru 05/05/2017 6

7 GASTROENTEROLOGY Stelara PSORIASIS Stelara if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred product Humira or a contraindication to its use. Kerry Pierson, R.Ph. Texas Lic #24228 GASTROENTEROLOGY Revlimid ONCOLOGY Approval Approved from 11/14/2016 thru 11/14/2017 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/15/2016 thru 11/15/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/17/2016 thru 11/17/2018 GASTROENTEROLOGY Serostim No Response GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/29/2016 thru 12/29/2018 GENERAL PRACTICE Vivitrol ALCOHOL DEPENDENCY Approval Approved from 11/18/2016 thru 11/18/2017 HEMATOLOGY Thalomid ONCOLOGY Approval Approved from 11/01/2016 thru 11/01/2017 HEMATOLOGY Revlimid ONCOLOGY Approval Approved from 11/04/2016 thru 11/04/2017 HEMATOLOGY & ONCOLOGY Votrient ONCOLOGY Current plan approved criteria do not allow coverage of Votrient if soft tissue subtype is liposarcoma. Jennifer To, PharmD, IL license: HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY No Response HEMATOLOGY & ONCOLOGY Zytiga ONCOLOGY Approval Approved from 11/07/2016 thru 11/07/2018 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 11/08/2016 thru 11/08/2017 HEMATOLOGY & ONCOLOGY Neupogen NEUTROPENIA Approval Approve for 6 months HEMATOLOGY & ONCOLOGY Revlimid ONCOLOGY Approval Approved from 11/10/2016 thru 11/10/2017 HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Approved from 11/11/2016 thru 11/11/2017 HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approve for 12 months. Max 800 mg/day. HEMATOLOGY & ONCOLOGY Sutent ONCOLOGY Approval Approved from 11/14/2016 thru 11/14/2017 HEMATOLOGY & ONCOLOGY Revlimid ONCOLOGY Approval Approved from 11/23/2016 thru 11/23/2017 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY capecitabine if the patient does not have a diagnosis of colorectal cancer, breast cancer, esophageal and esophagogastric junction cancer, gastric cancer, gallbladder cancer, intrahepatic cholangiocarcinoma, pancreatic neuroendocrine tumor (PNET) (islet cell tumors), ovarian cancer - epithelial ovarian cancer/fallopian tube, cancer/primary peritoneal cancer, pancreatic adenocarcinoma, central nervous system (CNS) metastases from breast cancer, penile cancer, occult primary cancer, head and neck cancer, renal cell carcinoma (RCC), lung neuroendocrine tumor (LNET), or anal cancer. Kerry Pierson, R.Ph. Texas Lic #

8 INTERNAL MEDICINE Octreotide Acetate ACROMEGALY Current plan approved criteria do not allow coverage of octreotide acetate injection if patient does not have advanced disease with multiple nodules, distant metastases, or unresectable disease. Octreotide acetate injection does not meet guidelines and it is denied. Jennifer To, PharmD, IL license: INTERNAL MEDICINE Sprycel ONCOLOGY No Response INTERNAL MEDICINE Afinitor ONCOLOGY Approval Approved from 11/07/2016 thru 11/07/2017 INTERNAL MEDICINE Repatha LIPID DISORDERS - PCSK9 INHIBITORS Repatha if the patient has not experienced statin-associated myositis (example, creatine kinase values should be adjusted 3 times the upper limit of normal above sex and racial norms AND either severe myalgia or weakness) or statin-associated rhabdomyolysis (example, creatine kinase level greater than 10,000 IU/L or accompanied by significant elevation in creatinine level). Kerry Pierson, R.Ph. Texas Lic #24228 INTERNAL MEDICINE Sprycel ONCOLOGY Approval Approved from 11/09/2016 thru 11/09/2017 INTERNAL MEDICINE Stivarga ONCOLOGY INTERNAL MEDICINE Cimzia INFLAMMATORY BOWEL DISEASE INTERNAL MEDICINE Temozolomide ONCOLOGY INTERNAL MEDICINE Enbrel RHEUMATOID ARTHRITIS MEDICAL ONCOLOGY Capecitabine ONCOLOGY Stivarga if the patient does not have a diagnosis of colorectal cancer or gastrointestinal stromal tumor (GIST). Kerry Pierson, R.Ph. Texas Lic #24228 Cimzia 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 Temodar (temozolomide) if the patient does not have a diagnosis of central nervous system lymphoma, supratentorial astrocytoma/oligodendroglioma, adult medulloblastoma, supratentorial primitive neuroectodermal tumor (PNET), brain metastases, glioblastoma, or anaplastic glioma. Kerry Pierson, R.Ph. Texas Lic # Current plan approved criteria do not allow coverage of Enbrel if there is missing clinical information including but not limited to the maximum titrated methotrexate dose. Phuc Duong,RPh, TX License #33014 capecitabine if the breast cancer is not recurrent or metatstatic. Phuc Duong,RPh, TX License #33014 MEDICAL ONCOLOGY Stivarga ONCOLOGY Approval Approved from 11/29/2016 thru 11/29/2017 NEPHROLOGY / RENAL MEDICINE Sensipar RENAL DISEASE Approval Approved from 11/15/2016 thru 11/15/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 11/01/2016 thru 05/01/2017 NEUROLOGY Tysabri MULTIPLE SCLEROSIS Approval Approved from 11/03/2016 thru 11/03/2018 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval Approved from 11/05/2016 thru 11/05/2017 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 11/08/2016 thru 11/08/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 11/09/2016 thru 05/09/2017 8

9 NEUROLOGY Rebif MULTIPLE SCLEROSIS Approval Approved from 11/10/2016 thru 11/10/2018 NEUROLOGY Botox BOTULINUM TOXINS No Response NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 11/16/2016 thru 05/16/2017 NEUROLOGY Zinbryta MULTIPLE SCLEROSIS Approval Approve for 24 months (max dose of 150 mg per 28 days) NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 11/21/2016 thru 11/21/2017 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approve for 30 days with a maximum dose of 20 mg per day. NEUROLOGY Botox BOTULINUM TOXINS No Response NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 11/29/2016 thru 11/29/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 11/30/2016 thru 05/30/2017 Humira RHEUMATOID ARTHRITIS Approval Approved from 11/01/2016 thru 11/01/2018 Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/15/2016 thru 11/15/2018 Botox BOTULINUM TOXINS Approval Approved from 11/21/2016 thru 05/21/2017 Repatha LIPID DISORDERS - PCSK9 INHIBITORS Repatha if the patient has not experienced statin-associated myositis (example, creatine kinase values should be adjusted 3 times the upper limit of normal above sex and racial norms AND either severe myalgia or weakness) or statin-associated rhabdomyolysis (example, creatine kinase level greater than 10,000 IU/L or accompanied by significant elevation in creatinine level). Kerry Pierson, R.Ph. Texas Lic #24228/ Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/14/2016 thru 11/14/2018 Zoledronic Acid OSTEOPOROSIS Approval Approved from 11/16/2016 thru 11/16/2018 Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/21/2016 thru 11/21/2018 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 11/08/2016 thru 05/08/2017 OBSTETRICS & GYNECOLOGY Neupogen NEUTROPENIA Approval Approved from 11/10/2016 thru 05/10/2017 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES No Response OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 11/14/2016 thru 05/14/2017 Stelara PSORIASIS Approval Approved from 11/01/2016 thru 11/01/2018 Vivitrol ALCOHOL DEPENDENCY Approval Approved from 11/03/2016 thru 11/03/2017 9

10 Repatha LIPID DISORDERS - PCSK9 INHIBITORS Repatha if the patient does not have a definite diagnosis of familial hypercholesterolemia (FH) confirmed by one of the following: a low-density lipoprotein (LDL) receptor mutation, familial defective apo B-100, or a PCSK9 gain-of-function mutation, or 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 (example. definite familial hypercholesterolemia). Kerry Pierson, R.Ph. Texas Lic #24228 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 PSYCHIATRY Vivitrol ALCOHOL DEPENDENCY No Response PSYCHIATRY Vivitrol ALCOHOL DEPENDENCY Approval Approved from 11/28/2016 thru 11/28/2017 PULMONARY DISEASES Orkambi CYSTIC FIBROSIS Current plan approved criteria does not allow coverage of Orkambi if the medication will be used in combination with Kalydeco (ivacaftor) and documentation of genetic test for positive F508del mutation is not provided. Phuc Duong,RPh, TX License #33014 RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval Approved from 11/01/2016 thru 11/01/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/01/2016 thru 11/01/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/01/2016 thru 11/01/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/03/2016 thru 11/03/2018 RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval Approved from 11/04/2016 thru 11/04/2018 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 11/07/2016 thru 11/07/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Benlysta SYSTEMIC LUPUS ERYTHE- MATOSUS Approved for 24 months starting 12/9/16 because current auth (PA # ) will have expired on 12/8/16 Approval Approved from 11/09/2016 thru 11/09/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/10/2016 thru 11/10/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Enbrel if the patient has not experienced an inadequate response after at least 3 months of treatment with methotrexate titrated to greater than or equal to 25mg/wk, intolerance, or contraindication to methotrexate. Deborah Claus, RPh, TX License #: RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/14/2016 thru 11/14/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Approve for 24 months with a maximum dose of 400 mg per 28 days. RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/15/2016 thru 11/15/

11 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per week. RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/16/2016 thru 11/16/2018 RHEUMATOLOGY Sensipar RENAL DISEASE Approval Approved from 11/17/2016 thru 11/17/2017 RHEUMATOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 11/17/2016 thru 05/17/2017 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/18/2016 thru 11/18/2018 RHEUMATOLOGY Cimzia INFLAMMATORY BOWEL DISEASE Approval Approved from 11/18/2016 thru 11/18/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/23/2016 thru 11/23/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Current plan approved criteria do not allow coverage of Enbrel if the maximum titrated methotrexate dose is less than 25 mg per week and there is no documentation of intolerance or contraindication to methotrexate. Phuc Duong,RPh, TX License #33014 Xeljanz if the patient does not have a diagnosis of rheumatoid arthritis. Phuc Duong,RPh, TX License # ANESTHESIOLOGY Vivitrol ALCOHOL DEPENDENCY Approval Approved from 12/15/2016 thru 12/15/2017 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/07/2016 thru 12/07/2018 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks. DERMATOLOGY Lupron Depot HORMONAL THERAPIES No Response FAMILY PRACTICE Stelara PSORIASIS Approval Approved from 12/01/2016 thru 12/01/2018 FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS Approval Approved from 12/07/2016 thru 12/07/2018 FAMILY PRACTICE Humira RHEUMATOID ARTHRITIS Approval Approved from 12/21/2016 thru 12/21/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks. GASTROENTEROLOGY Ampyra MULTIPLE SCLEROSIS No Response GASTROENTEROLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 12/09/2016 thru 06/09/2017 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Humira meets guidelines and it is approve for 24 months GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/20/2016 thru 12/20/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/29/2016 thru 12/29/2018 HEMATOLOGY Thalomid ONCOLOGY Approval Approved x 12 months. Approved from 12/12/2016 thru 12/12/2017 HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approve for 12 months HEMATOLOGY & ONCOLOGY Afinitor ONCOLOGY Approval Approved from 12/01/2016 thru 12/01/2017 HEMATOLOGY & ONCOLOGY Sutent ONCOLOGY Approval Approve for 12 months. Max dose 50 mg/day. HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval. Capecitabine meets guidelines and it is approve for 12 months. HEMATOLOGY & ONCOLOGY Capecitabine ONCOLOGY Approval Approved from 12/14/2016 thru 12/14/

12 HEMATOLOGY & ONCOLOGY Prolia OSTEOPOROSIS Approval Approve for 24 months (Max dose of 60 mg per 6 months) HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY Approval Approved for 12 months. Approved from 12/19/2016 thru 12/19/2017 HEMATOLOGY & ONCOLOGY Xtandi ONCOLOGY Approval Approved from 01/22/2017 thru 01/22/2019 HEMATOLOGY & ONCOLOGY Procrit ANEMIA Approval Approved from 12/29/2016 thru 03/23/2017 INTERNAL MEDICINE Capecitabine ONCOLOGY Approval Approved from 12/07/2016 thru 12/07/2017 INTERNAL MEDICINE Orkambi CYSTIC FIBROSIS Approval Approved from 12/09/2016 thru 12/31/2039 INTERNAL MEDICINE Jakafi ONCOLOGY Approval Approved from 12/23/2016 thru 12/23/2017 MEDICAL ONCOLOGY Neulasta NEUTROPENIA Approval Approved from 12/02/2016 thru 06/02/2017 NEPHROLOGY / RENAL MEDI- CINE, PEDIATRIC Epogen ANEMIA Approval Approved for 12 weeks. Approved from 12/29/2016 thru 03/23/2017 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 12/05/2016 thru 12/05/2018 NEUROLOGY Ampyra MULTIPLE SCLEROSIS No Response NEUROLOGY Botox BOTULINUM TOXINS Approval Approved for 12 months. Approved from 12/06/2016 thru 12/06/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 12/08/2016 thru 06/08/2017 NEUROLOGY Botox BOTULINUM TOXINS No Response NEUROLOGY Botox BOTULINUM TOXINS Botox if the patient has not completed an adequate trial (greater than or equal to 8 weeks) of oral migraine preventative therapy (examples: divalproex sodium, topriamate, gabapentin, amitriptyline, venlafaxine, atenolol/metoprolol/propranolol/timolol/nadolol, nimodipine/verapamil or naproxen/other non-steroidal anti-inflammatory drug). Kerry Pierson, RPh. Texas Lic #24228 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 12/12/2016 thru 06/12/2017 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 12/12/2016 thru 12/12/2017 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 01/09/2017 thru 01/09/2018 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Current plan approved criteria do not allow coverage of Ampyra if there is missing clinical information including but not limited to the patent s clinical response to Ampyra therapy. Phuc Duong,RPh, TX License #33014 NEUROLOGY Ampyra MULTIPLE SCLEROSIS No Response NEUROLOGY Norditropin NEUROLOGY Botox BOTULINUM TOXINS Approval Approval Approved from 01/15/2017 thru 01/15/2018 Approve for 12 months (maximum of 400 Units administered in a 12-week interval). NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 12/28/2016 thru 12/28/2018 NEUROLOGY Temozolomide ONCOLOGY Approval Approved from 12/29/2016 thru 12/29/2018 NEUROLOGY Botox BOTULINUM TOXINS Approval Approved from 12/29/2016 thru 06/29/2017 Vivitrol ALCOHOL DEPENDENCY Approval Approve for 12 months with a maximum dose of 380 mg per 28 days. 12

13 Botox BOTULINUM TOXINS Approval Approved for 6 months. Approved from 12/13/2016 thru 06/13/2017 Botox BOTULINUM TOXINS Approval Approved from 12/31/2016 thru 12/31/2017 Humira RHEUMATOID ARTHRITIS Approval Approved from 12/02/2016 thru 12/02/2018 OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES No Response OBSTETRICS & GYNECOLOGY Lupron Depot HORMONAL THERAPIES Approval Approved from 01/20/2017 thru 07/20/2017 PEDIATRICS Actemra RHEUMATOID ARTHRITIS Approval PHYSICIAN, ENDOCRINOL- OGY PHYSICIAN, ONCOLOGY, MEDICAL Approved for 24 months. Approved from 12/02/2016 thru 12/02/2018 Ibrance ONCOLOGY No Response Ampyra MULTIPLE SCLEROSIS Approval Approved from 12/28/2016 thru 01/27/2017 Repatha LIPID DISORDERS - PCSK9 INHIBITORS Repatha if the patient has not experienced any of the following adverse reactions to a previous treatment with a statin: statin-associated myositis (specifically, their creatine kinase values should be adjusted 3 times the upper limit of normal above sex and racial norms along with either severe myalgia or weakness); or statin-associated rhabdomyolysis (that is, had a creatine kinase level greater than 10,000 International Units per Liter or accompanied by significant elevation in creatinine level). Thao Trinh, Pharm.D, TX License # Tasigna ONCOLOGY Approval Approved from 12/12/2016 thru 12/12/2017 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/30/2016 thru 12/30/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/05/2016 thru 12/05/2018 RHEUMATOLOGY Forteo OSTEOPOROSIS Approval Approved from 12/06/2016 thru 06/06/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Humira unless the maximum titrated methotrexate dose is greater than or equal to 25 milligrams per week or the patient either experienced intolerance to methotrexate or had a contraindication to methotrexate. Thao Trinh, Pharm.D, TX License # Approved for 24 months. Approved from 12/12/2016 thru 12/12/2018 Approved x 24 months. Approved from 12/12/2016 thru 12/12/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/13/2016 thru 12/13/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/19/2016 thru 12/19/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved for 24 months. Approved from 12/23/2016 thru 12/23/2018 Humira meets guidelines and it is approve for 24 months with a maximum dose of 40 mg per 2 weeks. 13

14 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved for 24 months. Approved from 12/30/2016 thru 12/30/2018 UROLOGY Zytiga ONCOLOGY Approval Approved from 12/21/2016 thru 12/21/ HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Ibrance if the patient?s human epidermal growth factor receptor 2 (HER2) status is positive. Deborah Claus, RPh, TX License #: GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 01/20/2017 thru 01/20/ GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/22/2016 thru 12/22/ DERMATOLOGY Jakafi ONCOLOGY Approval Approved from 10/31/2016 thru 10/31/ FAMILY PRACTICE Repatha 3952 FAMILY PRACTICE Repatha LIPID DISORDERS - PCSK9 INHIBITORS LIPID DISORDERS - PCSK9 INHIBITORS No Response Repatha if any of the following documentation is not provided: statin-associated myositis (creatine kinase values should be adjusted 3 times the upper limit of normal above sex and racial norms and either severe myalgia or weakness) or statin-associated rhabdomyolysis (creatine kinase level greater than 10,000 IU/L or accompanied by significant elevation in creatinine level). Phuc Duong,RPh, TX License # GASTROENTEROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 10/17/2016 thru 10/17/ GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/19/2016 thru 10/19/ GASTROENTEROLOGY 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 INTERNAL MEDICINE Xeloda ONCOLOGY Approval Approved from 10/04/2016 thru 10/04/ INTERNAL MEDICINE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/11/2016 thru 10/11/ INTERNAL MEDICINE Xeloda ONCOLOGY Approval Approve for 12 months NEUROLOGY Rebif MULTIPLE SCLEROSIS Approval Approved from 10/04/2016 thru 10/04/ Humira RHEUMATOID ARTHRITIS Humira if the patient has not tried and had an inadequate response to at least one conventional therapy option (example, azathioprine [Azasan, Imuran], budesonide [Entocort EC], ciprofloxacin [Cipro], mesalamine [Asacol, Delzicol, Pentasa, Lialda], mercaptopurine [Purinethol], methylprednisolone [Solu-Medrol], methotrexate, metronidazole [Flagyl], prednisone, sulfasalazine [Azulfidine]) and there is no documented contraindication or intolerance to at least one conventional therapy option. Kerry Pierson, R.Ph. Texas Lic # Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks PEDIATRICS Neulasta NEUTROPENIA Approval Approved for 6 months RHEUMATOLOGY Actemra RHEUMATOID ARTHRITIS Approval 3952 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 162 mg per week. Approve for 24 months with a maximum dose of 50 mg per week. 14

15 3952 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/14/2016 thru 10/14/ RHEUMATOLOGY Xeljanz RHEUMATOID ARTHRITIS Approval Approved from 10/17/2016 thru 10/17/ RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/31/2016 thru 10/31/ UROLOGY Xtandi ONCOLOGY Approval Approved from 10/25/2016 thru 10/25/ DERMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/17/2016 thru 12/17/ FAMILY PRACTICE Repatha LIPID DISORDERS - PCSK9 INHIBITORS Repatha if the patient s current low density lipoprotein level is less than 100 mg/dl. Furthermore, current plan approved criteria does not allow coverage of 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). Richard Mendoza, PharmD, Texas License #: GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/09/2016 thru 11/09/ HEMATOLOGY & ONCOLOGY Hizentra IMMUNE DEFICIENCIES AND Hizentra if the patient does not have a diagnosis of primary immunedeficiency. Phuc Duong,RPh, TX License # HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Approved from 11/22/2016 thru 11/22/ MEDICAL ONCOLOGY Pulmozyme CYSTIC FIBROSIS Approval Approve 24 months, 5 mg per day PHYSICIAN, ONCOLOGY, MEDICAL Procrit ANEMIA Approval Approved from 11/26/2016 thru 02/18/2017 Stimate HEMOPHILIA Approval Approved from 11/02/2016 thru 12/31/ RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval 3952 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved for 24 months. Approved from 11/2/ /2/2018 Approve for 24 months with a maximum dose of 40 mg per 2 weeks RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/04/2016 thru 11/04/ RHEUMATOLOGY Procrit ANEMIA Current plan approved criteria do not allow coverage of Procrit if clinical information was inadequate to complete review. As a result, cannot determine whether or not this drug is medically necessary. Jennifer To, PharmD IL license: RHEUMATOLOGY Stelara PSORIASIS Approval Approved for 24 months 3952 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/29/2016 thru 11/29/ CARDIOLOGY Adcirca PULMONARY ARTERIAL HYPERTENSION Approval Approved from 12/28/2016 thru 12/28/ DERMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 01/15/2017 thru 01/15/

16 3952 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/20/2016 thru 12/20/ DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/23/2016 thru 12/23/ ENDOCRINOLOGY, DIABETES & METABOLISM Norditropin Approval Approved from 01/28/2017 thru 01/28/ FAMILY PRACTICE Sabril SEIZURE DISORDERS Approval Approved from 01/29/2017 thru 07/29/ HEMATOLOGY & ONCOLOGY Jakafi ONCOLOGY 3952 HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval 3952 INTERNAL MEDICINE Xeloda ONCOLOGY Approval Current plan approved criteria do not allow coverage of Jakafi if there has not been an inadequate response or intolerance to hydroxyurea. Phuc Duong,RPh, TX License # Approved x 12 months. Approved from 12/19/2016 thru 12/19/2017 Approved for 12 months. Approved from 12/23/2016 thru 12/23/ NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 12/06/2016 thru 12/06/ NEUROLOGY, PEDIATRIC Sabril SEIZURE DISORDERS Approval Approved from 01/14/2017 thru 07/14/ NEUROLOGY, PEDIATRIC Xenazine MOVEMENT DISORDERS 3952 NEUROLOGY, PEDIATRIC Xenazine MOVEMENT DISORDERS Approval 3952 Xenazine if the patient has not been evaluated for untreated or inadequately treated depression nor evaluated for active suicide ideation. Kerry Pierson, R.Ph. Texas Lic #24228 Approved x 12 months. Approved from 01/14/2017 thru 01/14/2018 Humira RHEUMATOID ARTHRITIS Approval Approved from 12/08/2016 thru 12/08/ RHEUMATOLOGY Rasuvo RHEUMATOID ARTHRITIS Approval Approved from 12/05/2016 thru 12/05/ RHEUMATOLOGY Rasuvo RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 30 mg per week RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response 3952 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/28/2016 thru 12/28/2018 DERMATOLOGY Otezla PSORIASIS Approval Approve for 24 months with a maximum dose of 60 mg per day. DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/13/2016 thru 10/13/2018 FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS No Response FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/14/2016 thru 10/14/2018 FAMILY PRACTICE Enbrel RHEUMATOID ARTHRITIS No Response GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Humira if the prior authorization criteria form has not been completed and submitted for review within the allotted time frame (urgent requests are closed within 72 hours, non-urgent requests are closed within 14 days). Thao Trinh, Pharm.D, TX License # GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/04/2016 thru 10/04/2018 GASTROENTEROLOGY Simponi RHEUMATOID ARTHRITIS Currrent plan approved criteria does not allow coverage of Simponi if there has not been an inadequate response, intolerance or confirmed adverse event to Humira. Phuc Duong,RPh, TX License #

17 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/18/2016 thru 10/18/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/18/2016 thru 10/18/2018 GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 40 mg per 2 weeks. GASTROENTEROLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/30/2016 thru 10/30/2018 HEMATOLOGY & ONCOLOGY Jakafi ONCOLOGY Jakafi if the patient does not have a diagnosis of primary myelofibrosis, secondary myelofibrosis due to polycythemia vera (PV) (post-pv myelofibrosis), secondary myelofibrosis due to essential thrombocythemia (ET) (post-et myelofibrosis), or polycythemia vera. Kerry Pierson, R.Ph. Texas Lic #24228 HEMATOLOGY & ONCOLOGY Nexavar ONCOLOGY No Response HEMATOLOGY & ONCOLOGY, PEDIATRIC Stimate HEMOPHILIA Approval Approved from 10/13/2016 thru 12/31/2039 INTERNAL MEDICINE Orencia RHEUMATOID ARTHRITIS No Response INTERNAL MEDICINE Forteo OSTEOPOROSIS Approval Approve a lifetime total of 24 months (Maximum of 20mcg per day) NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 10/06/2016 thru 10/06/2018 NEUROLOGY Aubagio MULTIPLE SCLEROSIS Approval Approved from 10/17/2016 thru 10/17/2018 NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approve for 24 months with a maximum dose of 480 mg per day. NEUROLOGY, PEDIATRIC Sabril SEIZURE DISORDERS Approval Approve for 6 months. PEDIATRICS Norditropin PEDIATRICS Norditropin Procrit ANEMIA No Response Procrit ANEMIA Approval Approved from 10/18/2016 thru 01/10/2017 Tecfidera MULTIPLE SCLEROSIS Approval Approved from 10/19/2016 thru 10/19/2018 Actemra RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 162 mg per week. Norditropin if the patient does not have a pretreatment IGF-1 level greater than 2 standard deviations (SD) below the mean. Kerry Pierson, R.Ph. Texas Lic#24228 Approval Approved from 11/20/2016 thru 11/20/2017 Stelara PSORIASIS Approval Approved from 10/18/2016 thru 10/18/2018 Repatha LIPID DISORDERS - PCSK9 INHIBITORS Approval Approved from 10/20/2016 thru 10/20/

18 PHYSICIAN, ENDOCRINOLO- GY & METABOLISM Otezla PSORIASIS Norditropin Otezla if there has not been an inadequate response, intolerance or confirmed adverse event to the preferred products (Enbrel or Humira) or a clinical reason to avoid their use. The clinical reason must be specified as a contraindication to Enbrel or Humira, history of demyelinating disorder, history of congestive heart failure, history of hepatitis B virus infection, or autoantibody formation/lupus-like syndrome. Thao Trinh, Pharm.D, TX License # Approval Approved from 10/04/2016 thru 10/04/2017 PULMONARY DISEASES Forteo OSTEOPOROSIS Approval Approved from 10/26/2016 thru 10/26/2018 RHEUMATOLOGY Otezla PSORIASIS RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS 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 Enbrel if the patient has not experienced an intolerance or contraindication to methotrexate. Kerry Pierson, R.Ph. Texas Lic #24228 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 10/10/2016 thru 10/10/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 10/12/2016 thru 10/12/2018 RHEUMATOLOGY Orencia RHEUMATOID ARTHRITIS Approval Approved from 10/14/2016 thru 10/14/2018 RHEUMATOLOGY Otrexup RHEUMATOID ARTHRITIS Approval RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval DERMATOLOGY Otezla PSORIASIS ENDOCRINOLOGY, PEDIATRIC Norditropin ENDOCRINOLOGY, PEDIATRIC Norditropin ENDOCRINOLOGY, PEDIATRIC Norditropin ENDOCRINOLOGY, PEDIATRIC Norditropin Approve for 24 months with a maximum dose of 25 mg per week. Approve for 24 months with a maximum dose of 50 mg per week. 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 Approval Approved from 12/01/2016 thru 12/01/2017 No Response Approval GASTROENTEROLOGY Humira RHEUMATOID ARTHRITIS Approval Approved for 12 months. Approved from 11/25/2016 thru 11/25/2017 Approval Approved from 11/15/2016 thru 11/15/2017 Approve for 24 months with a maximum dose of 40 mg per 2 weeks. HEMATOLOGY & ONCOLOGY Ibrance ONCOLOGY Approval Approved from 11/07/2016 thru 11/07/2017 HEMATOLOGY & ONCOLOGY Zytiga ONCOLOGY Approval Approve for 24 months; Max dose 1000 mg/day INTERNAL MEDICINE Adcirca PULMONARY ARTERIAL HYPERTENSION Approval Approved from 11/22/2016 thru 11/22/2017 MEDICAL ONCOLOGY Zytiga ONCOLOGY Approval Approve for 24 months; Max dose 1000 mg/day. 18

19 MEDICAL ONCOLOGY Pulmozyme CYSTIC FIBROSIS Approval Approved from 11/15/2016 thru 11/15/2018 NEUROLOGY Gilenya MULTIPLE SCLEROSIS Approval Approved from 11/02/2016 thru 11/02/2017 NEUROLOGY Rebif MULTIPLE SCLEROSIS Approval Approved from 11/01/2016 thru 11/01/2018 NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approve for 30 days with a maximum dose of 20 mg per day. NEUROLOGY Xenazine MOVEMENT DISORDERS Approval Approved from 11/22/2016 thru 11/22/2017 NEUROLOGY Tecfidera MULTIPLE SCLEROSIS Approval Approved from 11/23/2016 thru 11/23/2018 NEUROLOGY Ampyra MULTIPLE SCLEROSIS No Response NEUROLOGY Ampyra MULTIPLE SCLEROSIS Approval Approved from 12/18/2016 thru 12/18/2017 NURSE PRACTITIONER, ACUTE CARE Repatha LIPID DISORDERS - PCSK9 INHIBITORS 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). In addition, Current plan approved criteria do not allow coverage of Repatha if low density lipoprotein is less than 100mg/dl. Repatha does not meet guidelines and it is denied. Jennifer To, PharmD, Illinois license: Humira RHEUMATOID ARTHRITIS Approval Approved from 11/22/2016 thru 11/22/2018 RHEUMATOLOGY Simponi RHEUMATOID ARTHRITIS Approval Approve for 24 months with a maximum dose of 50 mg per 28 days RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/05/2016 thru 11/05/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 12/05/2016 thru 12/05/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 12/11/2016 thru 12/11/2017 RHEUMATOLOGY Otezla PSORIASIS Received an urgent outdated PA form for Otezla. Unable to complete the review with criteria form provided. Called MDO and left a message that the current PA form is being faxed to the MDO. Pending to clinician to review the clinical information. Case is due by 11/21 17:45 CST. RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS Approval Approved from 11/25/2016 thru 11/25/2018 RHEUMATOLOGY Enbrel RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS No Response RHEUMATOLOGY Simponi RHEUMATOID ARTHRITIS Approval Approved from 12/18/2016 thru 12/18/2018 RHEUMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 11/29/2016 thru 11/29/2018 RHEUMATOLOGY Forteo OSTEOPOROSIS Approval Approved from 11/30/2016 thru 11/30/