ACNE AGENTS_NVT_2018. Products Affected Adapalene External Cream Adapalene External Gel Adapalene-Benzoyl Peroxide Avita

Transcription

1 ACNE AGENTS_NVT_2018 Adapalene External Cream Adapalene External Gel Adapalene-Benzoyl Peroxide Avita Differin External Lotion Epiduo Forte Tretinoin External Tretinoin Microsphere PA Age Other 1

2 ADAGEN_NVT_2018 Adagen PA Age Other 2

3 ADEMPAS_NVT_2018 Adempas PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Pulmonologist or Cardiologist. For diagnosis of Pulmonary Arterial Hypertension, trial of one (1) of the following: Letairis, Opsumit or Tracleer. For diagnosis of Persistent/recurrent Chronic Thromboembolic Pulmonary Hypertension (CTEPH) (WHO Group 4), trial of prior therapy is not required. 3

4 AFINITOR_NVT_2018 Afinitor Afinitor Disperz PA Age Other 4

5 ALECENSA_NVT_2018 Alecensa PA Age Other Prescribed by, or in consultation with an Oncologist. 5

6 ALIQOPA Aliqopa PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None Follicular Lymphoma: Diagnosis of relapsed follicular lymphoma in patients who have received at least 2 prior systemic therapies 18 years of age and older Must be prescribed by, or in consultation with an oncologist 12 months Approve for continuation of therapy 6

7 ALUNBRIG_NVT_2018 Alunbrig PA Age Other Prescribed by, or in consultation with an Oncologist. 7

8 AMPYRA_NVT_2018 Ampyra PA Age Other Prescribed by, or in consultation with a Neurologist. 8

9 ANDROGENS_NON-PREFERRED_NVT_2018 Testosterone Transdermal Gel 12.5 MG/ACT (1%), 25 MG/2.5GM (1%), 50 MG/5GM (1%) Testosterone Transdermal Solution PA Age Other Two morning testosterone levels fall below the normal range for a healthy adult male. Patient must have tried and failed ANDRODERM and ANDROGEL. For formulary methyltestosterone product, if prescribed for delay in sexual development or metastasis from malignant tumor of breast, inoperable metastatic disease (skeletal) in women 1 to 5 years postmenopausal, testosterone levels and previous trial of ANDRODERM and ANDROGEL not required. For patients on testosterone replacement therapy, documentation of at least one (1) morning testosterone level from the last 12 months is required. 9

10 ANDROGENS_PREFERRED_NVT_2018 Androderm Transdermal Patch 24 Hour 2 MG/24HR, 4 MG/24HR AndroGel Pump Transdermal Gel MG/ACT (1.62%) AndroGel Transdermal Gel MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%) PA Age Other Two morning testosterone levels fall below the normal range for a healthy adult male. For patients on testosterone replacement therapy, documentation of at least one (1) morning testosterone level from the last 12 months is required. 10

11 APTIOM_NVT_2018 Aptiom PA Age Other 11

12 ARCALYST_NVT_2018 Arcalyst PA Age Other Prescribed by, or in consultation with a Rheumatology Specialist, Dermatology Specialist, or Immunologist. 12

13 ARIXTRA_NVT_2018 Fondaparinux Sodium PA Age Other Body weight less than 50 kg (venous thromboembolism prophylaxis only). If prescribed for acute DVT, patient must have a trial with or contraindication to enoxaparin. For all other FDA-approved indications, trial of enoxaparin not required. 13

14 ATYPICAL_ANTIPSYCHOTICS_NVT_2018 Abilify Maintena ARIPiprazole Oral Solution ARIPiprazole Oral Tablet Dispersible Aristada Fanapt Fanapt Titration Pack Invega Sustenna Invega Trinza Latuda Paliperidone ER RisperDAL Consta Saphris Vraylar PA Age Other Patient has tried and failed or was intolerant to 2 of the following for each indication: Bipolar Disorder: aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone. Schizophrenia: aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone. Irritability with Autistic Disorder: aripiprazole, risperidone. Patient has tried and failed or was intolerant to 1 of the following for each indication: Bipolar Depression: olanzapine. Major Depressive Disorder: aripiprazole. Tourette Syndrome: aripiprazole. Acute Manic/Mixed Episodes with Bipolar Disorder: aripiprazole. No trials required for the following indications: Schizoaffective Disorder. 14

15 AUBAGIO_NVT_2018 Aubagio PA Age Other For use in Multiple Sclerosis (MS), patient has a relapsing form of Multiple Sclerosis (MS). Prescribed by, or in consultation with a Neurologist or Multiple Sclerosis (MS) Specialist. For use in MS, patient has a relapsing form of MS and patient has tried dimethyl fumarate (Tecfidera) AND one of the following: beta-1a (Avonex), peginterferon beta-1a (Plegridy), or glatiramer (Copaxone). Exceptions to having tried an interferon product or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. 15

16 AURYXIA Auryxia PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Age Other None For the management of hyperphosphatemia in patients with chronic kidney disease on dialysis 18 years and older None 12 months None 16

17 AUSTEDO_NVT_2018 Austedo PA Age Other Patient has chorea due to Huntington's Disease. Patient has intolerance to or failure of therapy with tetrabenazine. Prescribed by, or in consultation with a Neurologist. 17

18 BELEODAQ_NVT_2018 Beleodaq PA Age Other Prescribed by, or in consultation with an Oncologist. 18

19 BOSULIF_NVT_2018 Bosulif PA Age Other Trial and failure or intolerance to imatinib, dasatinib (Sprycel) OR nilotinib (Tasigna). Prescribed by, or in consultation with an Oncologist. 19

20 BRIVIACT_NVT_2018 Briviact Intravenous Briviact Oral Solution Briviact Oral Tablet PA Age Other 20

21 BUPRENORPHINE SL_NVT_2018 Buprenorphine HCl Sublingual PA Age Other Patient is under prescriber supervision for the induction period for treatment of dependence to long-acting opioids or methadone. 21

22 CABOMETYX_NVT_2018 Cabometyx PA Age Other Prescribed by, or in consultation with an Oncologist. 22

23 CALQUENCE Calquence PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None MANTLE CELL LYMPHOMA (MCL) (1) Patient must have a diagnosis of MCL AND (2) Patient has tried one other therapy 18 years of age and older Must be prescribed by, or in consultation with an oncologist 12 months Approve for continuation of therapy 23

24 CAPRELSA_NVT_2018 Caprelsa PA Age Other Prescribed by, or in consultation with an Endocrinologist or Oncologist. 24

25 CARBAGLU_NVT_2018 Carbaglu PA Age Other 25

26 CAYSTON_NVT_2018 Cayston PA Age Other Prescribed by, or in consultation with an Infectious Disease Specialist or Pulmonology Specialist. 26

27 CESAMET_NVT_2018 Cesamet PA Age Other This drug may be covered under Medicare Part B or D depending upon the circumstances. may need to be submitted describing the use and setting of the drug to make the determination. 27

28 CHOLBAM_NVT_2018 Cholbam PA Age Other Prescribed by, or in consultation with a Hepatologist or Pediatric Gastroenterologist. Initial will be 3 months, then if criteria is met approved for the rest of the plan year. Renewal requires documentation of stable or improved liver function. 28

29 CINRYZE_NVT_2018 Berinert Cinryze Firazyr PA Age Other 29

30 COLCHICINE_NVT_2018 Colchicine Oral Tablet PA Age Other If for gout, trial of Mitigare required. If for Familial Mediterranean fever, trial of Mitigare is not required. 30

31 COMETRIQ_NVT_2018 Cometriq (100 mg Daily Dose) Cometriq (140 mg Daily Dose) Cometriq (60 mg Daily Dose) PA Age Other Prescribed by, or in consultation with an Oncologist. 31

32 CORLANOR_NVT_2018 Corlanor PA Age Other The patient is on a maximally tolerated dose of beta blocker or has a history of a documented intolerance, contraindication, or a hypersensitivity to beta blocker. Prescribed by, or in consultation with a Cardiology Specialist. 32

33 COSENTYX_NVT_2018 Cosentyx 300 Dose Cosentyx Sensoready 300 Dose PA Age Other Intolerance to or failure of therapy with Humira For Psoriatic Arthritis or Ankylosing Spondylitis: Prescribed by, or in consultation with Rheumatology Specialist. For Plaque Psoriasis: Prescribed by, or in consultation with a Dermatology Specialist. 33

34 COTELLIC_NVT_2018 Cotellic PA Age Other Prescribed by, or in consultation with an Oncologist. 34

35 CYRAMZA_NVT_2018 Cyramza PA Age Other Prescribed by, or in consultation with an Oncologist. 35

36 CYSTAGON_NVT_2018 Cystagon PA Age Other Prescribed by, or in consultation with an Endocrinologist, Geneticist, or Metabolic Physician. 36

37 CYSTARAN_NVT_2018 Cystaran PA Age Other For the treatment of corneal cystine crystal accumulation in patients with cystinosis. Prescribed by, or in consultation with an Ophthalmologist or Geneticist. 37

38 DARZALEX_NVT_2018 Darzalex Intravenous Solution 100 MG/5ML PA Age Other Prescribed by, or in consultation with an Oncologist. 38

39 DESOXYN_NVT_2018 Methamphetamine HCl PA Age Other 39

40 DRONABINOL_NVT_2018 Dronabinol Syndros PA Age Other Diagnosis of loss of appetite due to AIDS OR chemotherapy induced nausea and vomiting. This drug may be covered under Medicare Part B or D depending upon the circumstances. may need to be submitted describing the use and setting of the drug to make the determination. 40

41 EMPLICITI_NVT_2018 Empliciti PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 41

42 ENBREL_NVT_2018 Enbrel Subcutaneous Solution Prefilled Syringe Enbrel Subcutaneous Solution Reconstituted Enbrel SureClick Subcutaneous Solution Auto- Injector PA Age Other For moderate to severe RA or Psoriatic Arthritis requires Trial of or failure of therapy with methotrexate (at least 20mg/wk). Plaque Psoriasis: Trial of, or intolerance to, methotrexate at a dose of 15mg/week or trial of, or intolerance to, soriatane. For RA, Psoriatic Arthritis or Ankylosing Spondylitis: Prescribed by, or in consultation with a Rheumatology Specialist. For All Plaque Psoriasis: Prescribed by, or in consultation with a Dermatology Specialist. 42

43 ENDARI Endari PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None Approved diagnosis of acute sickle cell disease AND patient must have trial of Hydroxyurea OR intolerance to Hydroxyurea OR contraindication to Hydroxyurea 5 years of age and older 12 months 43

44 ENTRESTO_NVT_2018 Entresto PA Age Other Prescribed by, or in consultation with a Cardiology Specialist. 44

45 EPCLUSA_NVT_2018 Epclusa PA Age Other 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments Member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist duration of 12 weeks. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. For genotypes 1 and 4 only, failure or intolerance to Zepatier is required. 45

46 ERIVEDGE_NVT_2018 Erivedge PA Age Other Prescribed by, or in consultation with an Oncologist or Dermatologist. 46

47 ERLEADA Erleada PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Pregnancy Diagnosis of nonmetastatic, castration-resistant prostate cancer 18 years of age and older Prescribed by or in consultation with an oncologist or urologist 12 months 47

48 ERWINAZE_NVT_2018 Erwinaze Injection PA Age Other Prescribed by, or in consultation with an Oncologist. 48

49 EXONDYS_NVT_2018 Exondys 51 PA Age Other 49

50 FARYDAK_NVT_2018 Farydak PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 50

51 FERRIPROX_NVT_2018 Ferriprox PA Age Other Prescribed by, or in consultation with a Hematologist. 51

52 FIRMAGON_NVT_2018 Firmagon PA Age Other Prescribed by, or in consultation with an Oncologist or Urologist. 52

53 FOLOTYN_NVT_2018 Folotyn Intravenous Solution 40 MG/2ML PA Age Other Prescribed by, or in consultation with a Hematologist or Oncologist. 53

54 FORTEO_NVT_2018 Forteo Subcutaneous Solution 600 MCG/2.4ML PA Age Other Member has had at least 1 fracture, OR member has BMD screening results of -2.5 or below, OR member has previously used and failed a bisphosphonate. 54

55 FYCOMPA_NVT_2018 Fycompa PA Age Other 55

56 GARDASIL_NVT_2018 Gardasil 9 PA Age PA not required for members age Other 56

57 GATTEX_NVT_2018 Gattex PA Age Other Diagnosis of short bowel syndrome with less than 200cm of remnant functional intestine. Dependent on parenteral support for at least 12 months and at least 3 days per week. 57

58 GILENYA_NVT_2018 Gilenya Oral Capsule 0.5 MG PA Age Other For use in Multiple Sclerosis (MS), patient has a relapsing form of MS. Prescribed by, or in consultation with a Neurologist or Multiple Sclerosis (MS) Specialist. For use in MS, patient has a relapsing form of MS and patient has tried dimethyl fumarate (Tecfidera) AND one of the following: beta-1a (Avonex), peginterferon beta-1a (Plegridy), or glatiramer (Copaxone). Exceptions to having tried an interferon product or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. 58

59 GILOTRIF_NVT_2018 Gilotrif PA Age Other Prescribed by, or in consultation with an Oncologist. 59

60 GOCOVRI Gocovri PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Patients with ESRD (CrCl below 15 ml/min/m2) INITIAL: Diagnosis of Parkinsons disease AND (1) Patient is experiencing dyskinesia AND (2) Patient is receiving levodopa based therapy AND (3) Must have documented trial and failure to amantadine immediate release. RENEWAL: (1) must meet the initial criteria above AND (2) Documentation of positive clinical response to Gocovri (e.g., decreased "off" periods, decreased "on" time with troublesome dyskinesia) None Prescribed by or in consultation with a neurologist 12 months None 60

61 GROWTH HORMONES_NVT_2018 Norditropin FlexPro PA Age Other The criteria for approval of growth hormones in adults require the diagnosis of Somatropin Deficiency Syndrome (defined by failure to stimulate Growth Hormone secretion (peak GH level of 10mcg/L or less) by one of the acceptable provocative tests). This may include adults who as children had Growth Hormone deficiency or adults with known pituitary disease. 61

62 HETLIOZ_NVT_2018 Hetlioz PA Age Other Patient is totally blind. 62

63 HOFH_NVT_2018 Juxtapid Kynamro Subcutaneous Solution Prefilled Syringe PA Age Other Untreated LDL greater than 500 mg/dl OR treated LDL greater than or equal to 300 mg/dl. Concurrent use of maximum statin dose (atorvastatin or rosuvastatin) and one other lipid lowering agent (include dates and reasons for discontinuation). For patients with statin intolerance, concurrent use of maximum statin dose not required. Chart documentation showing the most recent full lipid panel, including Apo-B within the past 12 months. Prescribed by, or in consultation with a Lipidologist, Cardiologist, or an Endocrinologist. 63

64 HUMIRA_NVT_2018 Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit Humira Pen Subcutaneous Pen-Injector Kit Humira Pen-CD/UC/HS Starter Humira Pen-Ps/UV Starter Humira Subcutaneous Prefilled Syringe Kit PA Age Other For moderate to severe RA or Psoriatic Arthritis requires intolerance to or failure of therapy with methotrexate (at least 20mg/wk). Plaque Psoriasis: Failure of, or intolerance to, methotrexate at a dose of 15mg/week or failure of, or intolerance to, soriatane. If for Hidradenitis Suppurativa (HS), patient must have at least 3 cysts. For RA, Psoriatic Arthritis or Ankylosing Spondylitis: Prescribed by, or in consultation with a Rheumatology Specialist. For All Plaque Psoriasis and Hidradenitis Suppurativa (HS): Prescribed by, or in consultation with a Dermatology Specialist. 64

65 HYDROXYPROGESTERONE_NVT_2018 Hydroxyprogesterone Caproate Intramuscular Solution PA Age Other 65

66 IBRANCE_NVT_2018 Ibrance PA Age Other Prescribed by, or in consultation with an Oncologist. 66

67 ICLUSIG_NVT_2018 Iclusig PA Age Other Prescribed by, or in consultation with an Oncologist. 67

68 IDHIFA IDHIFA PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None Diagnosis of relapsed or refractory acute myeloid leukemia with an isocitrate dehydrogenase 2 mutation as detected by an FDA approved test age 18 years and older Prescribed by or in consultation with an oncologist 12 months None 68

69 IMATINIB_NVT_2018 Imatinib Mesylate PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 69

70 IMBRUVICA_NVT_2018 Imbruvica Oral Capsule 140 MG, 70 MG Imbruvica Oral Tablet 140 MG, 280 MG, 420 MG, 560 MG PA Age Other Prescribed by, or in consultation with an Oncologist or Hemotologist. 70

71 IMFINZI_NVT_2018 Imfinzi PA Age Other Prescribed by, or in consultation with an Oncologist. 71

72 INCRELEX_NVT_2018 Increlex PA Age Other For the long-term treatment of growth failure in children with severe primary insulin-like growth factor-1 (IGF-1) deficiency (primary IGFD) or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH. 72

73 INLYTA_NVT_2018 Inlyta PA Age Other Prescribed by, or in consultation with an Oncologist. 73

74 INTRAROSA Intrarosa PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Vaginal bleeding or dysfunctional uterine bleeding of an undetermined origin, known or suspected estrogen-dependent neoplasia. Diagnosis of moderate to severe dyspareunia or atrophic vaginitis AND A) Patient must be female, B) Patient must be menopausal or postmenopausal, C) Patient has tried and failed, has a contraindication or intolerance to a low dose vaginal estrogen preparation (e.g. Premarin vaginal cream, Estrace vaginal cream, Estring, Vagifem), D) Patient does not have renal or hepatic impairment. 18 years of age and older None Initial: 3 months, Reauthorization: 12 months None 74

75 IPF_NVT_2018 Esbriet Ofev PA Age Other Definitive diagnosis of idiopathic pulmonary fibrosis defined by the following: No known cause of lung fibrosis AND one of the following: A. Surgical lung biopsy revealing histopathological pattern of unspecified interstitial pneumonia (UIP) B. High-resolution computed tomography indicates definite UIP pattern C. High-resolution computed tomography indicates possible UIP pattern AND surgical lung biopsy reveals a histopathological pattern of probable UIP. Prescribed by, or in consultation with an Oncologist or Pulmonologist. Will not be used in combination with other medications used to treat IPF. 75

76 IRESSA_NVT_2018 Iressa PA Age Other Prescribed by, or in consultation with an Oncologist. 76

77 ISTODAX_NVT_2018 Istodax (Overfill) PA Age Other Prescribed by, or in consultation with a Hematologist or an Oncologist. 77

78 ITRACONAZOLE_NVT_2018 Itraconazole Oral Capsule PA Age Other For onychomycosis or diffuse dermatologic fungal infections: 1. If not prescribed by a Dermatologist or Podiatrist OR fungal infection is confirmed by a positive KOH test. 2. For onychomycosis, must fail terbinafine. For dermatologic infections, must fail one topical anti-fungal medication. Prescribed by, or in consultation with an Infectious Disease Specialist, Pulmonary Specialist, or Dermatology Specialist. Approved for 6 months. 78

79 IVIG_NVT_2018 Bivigam Intravenous Solution 10 GM/100ML Carimune NF Intravenous Solution Reconstituted 6 GM Flebogamma DIF Intravenous Solution 5 GM/50ML GamaSTAN S/D Intramuscular Injectable (10ML), (2ML) Gammagard Injection Solution 2.5 GM/25ML Gammagard S/D Less IgA Gammaked Injection Solution 1 GM/10ML Gammaplex Intravenous Solution 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 5 GM/50ML Gamunex-C Injection Solution 1 GM/10ML Octagam Intravenous Solution 1 GM/20ML, 2 GM/20ML Privigen Intravenous Solution 20 GM/200ML PA Age Other Approval will be based off BvD coverage determination. 79

80 JAKAFI_NVT_2018 Jakafi PA Age Other Prescribed by, or in consultation with a Hematologist or an Oncologist. 80

81 JYNARQUE Jynarque PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D History of significant liver impairment or injury, uncorrected abnormal blood sodium concentrations, patient is hypovolemic, anuric, or has an uncorrected urinary outflow obstruction Diagnosis of: A) Hypervolemic and euvolemic hyponatremia (i.e., serum sodium less than 125 meq per L or less marked hyponatremia that is symptomatic and has resisted correction with fluid restriction), including in patients with heart failure and syndrome of inappropriate antidiuretic hormone (SIADH) OR B) Autosomal dominant polycystic kidney disease (ADPKD). 18 years of age and older Initial - 6 months. Renewal - 12 months. None 81

82 KADCYLA_NVT_2018 Kadcyla PA Age Other 82

83 KALYDECO_NVT_2018 Kalydeco PA Age Other Prescribed by, or in consultation with a Pulmonologist. 83

84 KEYTRUDA_NVT_2018 Keytruda Intravenous Solution PA Age Other Prescribed by, or in consultation with an Oncologist. 84

85 KORLYM_NVT_2018 Korlym PA Age Other 85

86 KUVAN_NVT_2018 Kuvan PA Age Other For continuing therapy the patient must have shown a 20% drop in Phenylalanine levels after 2 months of Kuvan treatment. Prescribed by, or in consultation with a Geneticist or Metabolic Physician. Initial approval of 3 months, then if critieria is met, approved for the rest of the contract year. 86

87 KYPROLIS_NVT_2018 Kyprolis Intravenous Solution Reconstituted 30 MG, 60 MG PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 87

88 LARTRUVO_NVT_2018 Lartruvo PA Age Other Prescribed by, or in consultation with an Oncologist. 88

89 LENVIMA_NVT_2018 Lenvima 10 MG Daily Dose Lenvima 14 MG Daily Dose Lenvima 18 MG Daily Dose Lenvima 20 MG Daily Dose Lenvima 24 MG Daily Dose Lenvima 8 MG Daily Dose PA Age Other Prescribed by, or in consultation with an Oncologist. 89

90 LETAIRIS_NVT_2018 Letairis PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Cardiologist or Pulmonologist. 90

91 LEUKINE_NVT_2018 Leukine Intravenous PA Age Other Trial of or intolerance to filgrastim-sndz (Zarxio) AND tbo-filgrastim (Granix). 91

92 LIDOCAINE PATCH_NVT_2018 Lidocaine External Patch 5 % PA Management of neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia. Age Other Trial and failure of gabapentin of four weeks or more. 92

93 LONSURF_NVT_2018 Lonsurf PA Age Other Prescribed by, or in consultation with an Oncologist. 93

94 LYNPARZA_NVT_2018 Lynparza PA Age Other Prescribed by, or in consultation with an Oncologist. 94

95 MAVYRET Mavyret PA Age Other 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments Member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist of approval per AASLD Guidelines Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. For genotypes 1 and 4 only, failure or intolerance to Zepatier is required. 95

96 MEGESTROL SUSP_NVT_2018 Megestrol Acetate Oral Suspension 40 MG/ML, 625 MG/5ML PA Age Other 96

97 MEGESTROL TABS_NVT_2018 Megestrol Acetate Oral Tablet PA Age Other 97

98 MEKINIST_NVT_2018 Mekinist PA Age Other Prescribed by, or in consultation with an Oncologist. 98

99 MOVANTIK_NVT_2018 Movantik PA Age Other Initial Therapy: Member must meet all criteria. 1. Opioid-induced constipation. 2. Trial and failure of polyethylene glycol (Miralax/Glycolax) 99

100 MYLOTARG Mylotarg Intravenous Solution Reconstituted 4.5 MG PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None INITIAL: A. Newly- diagnosed, CD33 positive acute myeloid leukemia (AML) or B. Relapsed or refractory CD33 positive AML. CONTINUATION OF THERAPY: 1) patient continues to meet initial criteria and 2) patients with newly diagnosed AML have not exceeded a maximum of 8 cycles Relapsed of refractory AML: 2 years and older, Newly diagnosed AML: 18 years and older Prescribed by or in consultation with an oncologist 12 months None 100

101 NATPARA_NVT_2018 Natpara PA Age Other Prescribed by, or in consultation with an Endocrinologist. 101

102 NERLYNX Nerlynx PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Women who are preganant or breastfeeding Diagnosis of early stage HER2- overexpressed breast cancer. Must be used after trastuzumab therapy. age 18 years and older Prescribed by or in consultation with an oncologist 12 months None 102

103 NEXAVAR_NVT_2018 NexAVAR PA Age Other Member must be 18 years of age or older. Prescribed by, or in consultation with an Oncologist. 103

104 NINLARO_NVT_2018 Ninlaro PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 104

105 NORTHERA_NVT_2018 Northera PA Age Other Prescribed by, or in consultation with a Neurologist or Cardiologist. 105

106 NOXAFIL_NVT_2018 Noxafil Oral PA Age Other 106

107 NUCALA_NVT_2018 Nucala PA Age Other Peripheral blood eosinophil count of greater than or equal to 150 cells per microliter. History of 2 or more exacerbations in the previous year despite regular use of high-dose inhaled corticosteroids plus an additional controller(s). An exception is made for patients with intolerance or contraindication to high-dose inhaled corticosteroids and additional controller(s). Member must be 12 years of age or older. Prescribed by, or in consultation with an Allergy Specialist, Immunologist, or Pulmonary Specialist. 107

108 NUEDEXTA Nuedexta PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Diagnosis of heart failure, QT prolongation, congenital long QT syndrome, history suggestive of torsade de pointes, complete AV block without implanted pacemakers, high risk of complete AV block OR concurrent MAOI therapy or utilization within the preceding 14 days of initiating Nuedexta. Diagnosis of pseudobulbar affect caused by a structural neurologic condition such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), or stroke. 18 years of age and older Prescribed by or in consultation with a neurologist 12 months None 108

109 NUPLAZID_NVT_2018 Nuplazid Oral Tablet 17 MG PA Age Other 109

110 NUVIGIL_NVT_2018 Armodafinil Modafinil PA Age Other Diagnosis of narcolepsy, OR obstructive sleep apnea/hypopnea syndrome, OR shift work sleep disorder. 110

111 OCALIVA_NVT_2018 Ocaliva PA Age Other Prescribed by, or in consultation with a Hepatologist or Gastroenterologist. For use in treatment of primary biliary cholangitis, patient has had an inadequate response to a year of therapy with ursodiol or experienced intolerance to ursodiol. 111

112 ODOMZO_NVT_2018 Odomzo PA Age Other Prescribed by, or in consultation with an Oncologist or Dermatologist. 112

113 ONFI_NVT_2018 Onfi Oral Suspension Onfi Oral Tablet 10 MG, 20 MG PA Age Other 113

114 OPDIVO_NVT_2018 Opdivo Intravenous Solution 100 MG/10ML, 40 MG/4ML PA Age Other Prescribed by, or in consultation with an Oncologist. 114

115 OPSUMIT_NVT_2018 Opsumit PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Cardiologist or Pulmonologist. 115

116 ORAL FENTANYL_NVT_2018 FentaNYL Citrate Buccal Fentora Buccal Tablet 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG PA Age Other Breakthrough cancer pain and opioid tolerance. Documented tolerance to opioids defined as patients taking around the clock medicine consisting of at least 60mg of oral morphine daily, at least 25mcg of transdermal fentanyl per hour, at least 30mg of oxycodone daily, at least 8mg of oral hydromorphone daily, or an equianalgesic dose of another opioid daily for a week or longer. 116

117 ORENCIA_NVT_2018 Orencia ClickJect Orencia Intravenous Orencia Subcutaneous Solution Prefilled Syringe PA Age Other For moderate to severe RA intolerance to or failure of therapy with Enbrel OR Humira. For Polyarticular Juvenile Idiopathic Arthritis intolerance to or failure of therapy with Enbrel. Prescribed by, or in consultation with a Rheumatology Specialist. 117

118 ORFADIN_NVT_2018 Orfadin PA Age Other 118

119 ORKAMBI_NVT_2018 Orkambi Oral Tablet PA Age Other 1) Lung function (FEV1, ppfev1), 2) BMI, 3) Pulmonary exacerbation history to be collected initially and at continuation. Prescribed by, or in consultation with a Pulmonologist. Initial and continuation approval of 6 months to assess required medical info. 119

120 OSPHENA Osphena PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Vaginal bleeding or dysfunctional uterine bleeding of an undetermined origin, known or suspected estrogen-dependent neoplasia, acute thromboembolism or a past history of thromboembolic disease (including patients with a history of DVT, pulmonary embolism, retinal vein thrombosis, stroke, or myocardial infarction, known or suspected pregnancy. Diagnosis of moderate to severe dyspareunia or atrophic vaginitis AND A) Patient must be female, B) Patient must be menopausal or postmenopausal, C) Patient has tried and failed, has a contraindication or intolerance to a low dose vaginal estrogen preparation (e.g. Premarin vaginal cream, Estrace vaginal cream, Estring, Vagifem), D) Dose must not exceed 1 tablet per day, E) Osphena will not be used with estrogens, estrogen agonist-antagonists, fluconazole or rifampin, F) Patient does not have hepatic impairment. 18 years of age and older None Initial: 2 months, Reauthorization: 12 months None 120

121 PCSK9_NVT_2018 Praluent Subcutaneous Solution Pen-Injector Repatha Repatha Pushtronex System Repatha SureClick PA Age Other For initiation of therapy patient must: A) have one of the following conditions: 1) prior clinical atherosclerotic cardiovascular disease (ASCVD) (see Other ), 2) heterozygous familial hypercholesterolemia (HeFH) (see Other ), or 3) homozygous familial hypercholesterolemia (HoFH) (see Other ), AND B) for patients with prior clinical ASCVD or HeFH, current LDL-C level is over 100 mg/dl or over 70 mg/dl with diabetes, AND one of the following requirements is met: 1) patient has been treated for 8 weeks or more with a high intensity statin (atorvastatin 40mg or greater OR rosuvastatin 20mg or greater), OR 2) patient is intolerant to statins demonstrated by the failure of 2 statins, including an attempt with a low- or alternatively-dosed statin (twice weekly low-dose rosuvastatin or atorvastatin, low-intensity pitavastatin or pravastatin). For continuation of therapy, patient must: A) have one of the following conditions: 1) prior clinical ASCVD (see Other ), 2) HeFH (see Other ), or 3) HoFH (see Other ), AND B) demonstrate a reduction of LDL-C on PCSK9 inhibitor therapy. Prescribed by or in consultation with a Cardiologist, Lipidologist, or Endcrinologist Clinical ASCVD defined as acute coronary syndromes, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization procedure, prior stroke or transient ischemic attack, or 121

122 PA peripheral arterial disease of presumed atherosclerotic origin. Diagnosis of HeFH must be confirmed by one of the following: 1) DNA-based evidence of mutation in the LDLR, Apo B, OR PCSK9 gain of function mutation, 2) Untreated LDL-C greater than 190 mg/dl AND tendon xanthomas in patient or first/second degree relative, 3) Untreated LDL-C greater than 190 mg/dl AND either first degree relative less than 60 years of age or second degree relative less than 50 years of age with premature heart disease, OR 4) untreated LDL-C greater than 190 mg/dl AND first or second degree relative with total cholesterol greater than 290 mg/dl. Diagnosis of HoFH confirmed by the following: 1) two parents diagnosed with HeFH OR genetic confirmation of LDL receptor mutation, AND 2) untreated total cholesterol greater 290 mg/dl or LDL-C greater 190 mg/dl, AND 3) either xanthomas present at 10 years of age or younger OR atherosclerotic disease at 20 years of age or younger. 122

123 PERJETA_NVT_2018 Perjeta PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 123

124 POMALYST_NVT_2018 Pomalyst PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 124

125 PROGESTERONE_NVT_2018 Crinone PA Age Other 125

126 PROMACTA_NVT_2018 Promacta PA Age Other 126

127 RAVICTI_NVT_2018 Ravicti PA Age Other Requires trial of sodium phenylbutyrate powder. Prescribed by, or in consultation with a Metabolic Physician or Geneticist. 127

128 RELISTOR_NVT_2018 Relistor Subcutaneous Solution PA Age Other For the treatment of opioid-induced constipation (OIC) in adults with advanced illness who are receiving palliative care when response to laxative therapy has not been sufficient, member must have tried and failed 2 laxative/bowel therapies - polyethylene glycol + lactulose. For the treatment of OIC in adults with chronic non-cancer pain, member must have tried and failed Movantik. Approved for 4 months, subject to formulary change and member eligibility. 128

129 REVATIO_NVT_2018 Sildenafil Citrate Oral Tablet 20 MG PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Pulmonologist or Cardiologist. 129

130 REVLIMID_NVT_2018 Revlimid PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 130

131 RIBOCICLIB_NVT_2018 Kisqali 200 Dose Kisqali 400 Dose Kisqali 600 Dose Kisqali Femara 200 Dose Kisqali Femara 400 Dose Kisqali Femara 600 Dose PA Age Other Prescribed by, or in consultation with an Oncologist. 131

132 RITUXAN_NVT_2018 Rituxan Intravenous Solution PA Age Other For RA only: intolerance to or failure of therapy with Enbrel AND Humira. Prescribed by, or in consultation with an Oncologist or Rheumatology Specialist. 132

133 ROZEREM_NVT_2018 Rozerem PA Age Other For approval, a prior use of zolpidem is required OR patient has had history of scheduled drug dependence. 133

134 RUBRACA_NVT_2018 Rubraca PA Age Other Prescribed by, or in consultation with an Oncologist. 134

135 RUCONEST_NVT_2018 Ruconest PA Age Other 135

136 RYDAPT_NVT_2018 Rydapt PA Age Other Prescribed by, or in consultation with an Oncologist. 136

137 SABRIL_NVT_2018 Sabril Oral Tablet Vigabatrin PA Age Other Prescribed by, or in consultation with a Neurologist. 137

138 SIGNIFOR_NVT_2018 Signifor PA Age Other Prescribed for the treatment of an adult patient with Cushing disease AND Pituitary surgery is not an option OR Pituitary surgery was not curative. Prescribed by, or in consultation with an Endocrinologist. 138

139 SIMPONI ARIA_NVT_2018 Simponi Aria PA Age Other For moderate to severe RA, intolerance to or failure of therapy with Enbrel AND Humira. Prescribed by a Rheumatology Specialist. 139

140 SIRTURO_NVT_2018 Sirturo PA Age Other Prescribed by, or in consultation with an Infectious Disease Specialist. 140

141 SIVEXTRO_NVT_2018 Sivextro PA Age Other Prescribed by, or in consultation with an Infectious Disease Specialist. Approved for 6 months subject to formulary change and member eligibility. 141

142 SOLARAZE_NVT_2018 Diclofenac Sodium Transdermal Gel 3 % PA Age Other 142

143 SOLTAMOX_NVT_2018 Soltamox PA Age Other 143

144 SOMAVERT_NVT_2018 Somavert PA Age Other Prescribed by, or in consultation with an Endocrinologist. 144

145 SPRITAM_NVT_2018 Spritam PA Age Other Member must have a trial or contraindication to generic levetiracetam. 145

146 SPRYCEL_NVT_2018 Sprycel PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 146

147 STIVARGA_NVT_2018 Stivarga PA Age Other Prescribed by, or in consultation with an Oncologist. 147

148 STRENSIQ_NVT_2018 Strensiq Subcutaneous Solution 40 MG/ML, 80 MG/0.8ML PA Age Other Prescribed by, or in consultation with an Endocrinologist, Pediatric Endocrinologist, Metabolic Physician, or Geneticist. 148

149 SUCRAID_NVT_2018 Sucraid PA Age Other 149

150 SUTENT_NVT_2018 Sutent PA Age Other Prescribed by, or in consultation with an Oncologist. 150

151 SYLATRON_NVT_2018 Sylatron Subcutaneous Kit 200 MCG, 300 MCG, 600 MCG PA Age Other Prescribed by, or in consultation with an Oncologist. 151

152 SYMDEKO Symdeko PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None Diagnosis of cystic fibrosis and patient is homozygous for the F508del mutation OR have at least one mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that is responsive to tezacaftor/ivacaftor verified by an FDA-cleared CF mutation test 12 years of age and older None Initial-6 months. renewal-12 months. 152

153 SYNAGIS_NVT_2018 Synagis PA Age Other Approve up to five (MAXIMUM) monthly doses of Synagis when an infant or child meets the criteria for one of the following conditions: Infants and children younger than 24 months with chronic lung disease of prematurity (CLD previously known as bronchopulmonary dysplasia) receiving medical therapy within 6 months before the start of the RSV season OR Infants born before 32 weeks of gestation even if they do not have CLD OR Infants born at 32 to less than 35 weeks of gestation, particularly when at least 1 of the following 2 risk factors is present: the infant attends child care, or 1 or more siblings or other children younger than 5 years live permanently in the same household OR Infants with congenital abnormalities of the airway or neuromuscular disease OR Infants and children 24 months or younger with hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD). Prescribed by, or in consultation with an ICU Physician, Neonatologist, Pediatrician, Pulmonologist, Cardiologist, Infectious Disease Physician or Neurologist. 153

154 SYPRINE_NVT_2018 Trientine HCl PA Age Other 154

155 TAFINLAR_NVT_2018 Tafinlar PA Age Other Prescribed by, or in consultation with an Oncologist. 155

156 TAGRISSO_NVT_2018 Tagrisso PA Age Other Prescribed by, or in consultation with an Oncologist. 156

157 TARCEVA_NVT_2018 Tarceva PA Age Other Prescribed by, or in consultation with an Oncologist. 157

158 TARGRETIN_NVT_2018 Bexarotene PA Age Other Prescribed by, or in consultation with an Oncologist or Dermatologist. 158

159 TASIGNA_NVT_2018 Tasigna PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 159

160 TAVALISSE Tavalisse PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Uncontrolled or poorly controlled hypertension A. CHRONIC IMMUNE THROMBOCYTOPENIA.: INITIAL : (1) must attest to a clinical diagnosis of persistent or chronic immune thrombocytopenia for at least 3 months AND (2a) patient has had an insufficient response to ONE of the following previous therapies: corticosteroids, immunoglobulin, anti-d immunoglobulin, Promacta, Nplate, or Rituxan OR (2b) patient has undergone a splenectomy 18 years of age and older Prescribed by or in consultation with hematologist Initial -16 weeks. Renewal - 12 months None 160

161 TECENTRIQ_NVT_2018 Tecentriq PA Age Other Prescribed by, or in consultation with an Oncologist. 161

162 TETRABENAZINE_NVT_2018 Tetrabenazine PA Age Other Patient has chorea due to Huntington's Disease. Prescribed by, or in consultation with a Neurologist. 162

163 THALOMID_NVT_2018 Thalomid PA Age Other Prescribed by, or in consultation with an Oncologist. 163

164 TIGAN_NVT_2018 Trimethobenzamide HCl Oral PA Age Other 164

165 TOBI_NVT_2018 Tobi Podhaler Tobramycin Inhalation PA Age Other Prescribed by, or in consultation with an Infectious Disease Physician or Pulmonology Specialist. Approval will be based off BvD coverage determination. 165

166 TOPICAL STEROIDS_NVT_2018 Amcinonide External Cream Amcinonide External Ointment Betamethasone Valerate External Foam Clobetasol Propionate E Clobetasol Propionate External Clodan External Shampoo Desonide External Cream Desonide External Lotion Diflorasone Diacetate External Fluticasone Propionate External Lotion Psorcon PA Age Other Requires trial of two formulary topical steroids 166

167 TRACLEER_NVT_2018 Tracleer PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Pulmonologist or Cardiologist. 167

168 TREANDA_NVT_2018 Treanda Intravenous Solution Reconstituted PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 168

169 TROKENDI_NVT_2018 Qudexy XR Topiramate ER Trokendi XR PA Age Other Patient has tried and failed topiramate (TOPAMAX) AND Patient has a diagnosis of partial-onset seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome OR is using for prophylaxis of migraine headache. 169

170 TYKERB_NVT_2018 Tykerb PA Age Other Tykerb is prescribed in combination with capecitabine (Xeloda) AND The patient has advanced or metastatic breast cancer with tumor overexpression of HER2 AND The patient has received prior therapy including an anthracycline and a taxane and trastumab. Tykerb is prescribed in combination with letrozole for the treatment of postmenopausal women with hormone receptor positive metastatic breast cancer that overexpresses the HER2 receptor for whom hormonal therapy is indicated. Prescribed by, or in consultation with an Oncologist. 170

171 TYMLOS Tymlos PA Covered Uses All medically accepted indications not otherwise excluded from Part D. Age Other None Documentation of high risk for fracture for postmenopausal women AND trial and failure, contraindication, or intolerance to one osteoporosis treatment (e.g., alendronate, risedronate, zoledronic acid, Prolia (denosumab)). High risk defined with the presence of two of the following: low BMD scores (T-score less than or equal to -2.5 at the spine or hip or both), age greater than 70, or history of osteoporotic fracture. None None Initial: 1 year Reauth: Treatment duration has not exceeded 24 months during pt lifetime None 171

172 TYSABRI_NVT_2018 Tysabri PA Age Other For use in Multiple Sclerosis (MS), patient has a relapsing form of MS. If for MS: Prescribed by, or in consultation with a Neurologist or a Multiple Sclerosis (MS) Specialist. For use in MS, patient has a relapsing form of MS and patient has tried dimethyl fumarate (Tecfidera) AND one of the following: beta-1a (Avonex), peginterferon beta-1a (Plegridy), or glatiramer (Copaxone). Exceptions to having tried an interferon product or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. 172

173 UCERIS_NVT_2018 Uceris Oral Uceris Rectal PA Age Other Patient has active mild to moderate ulcerative colitis and has tried and failed or was intolerant to mesalamine. 173

174 UPTRAVI_NVT_2018 Uptravi Oral Tablet Uptravi Oral Tablet Therapy Pack PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Pulmonologist or Cardiologist. 174

175 VALCHLOR_NVT_2018 Valchlor PA Age Other Patient has received prior skin-directed therapy such as topical steroids. Prescribed by, or in consultation with an Oncologist or Dermatologist. 175

176 VASCEPA_NVT_2018 Vascepa PA Age Other Patient has triglyceride level greater than or equal to 500 mg/dl. 176

177 VELTASSA_NVT_2018 Veltassa PA Age Other 177

178 VENCLEXTA_NVT_2018 Venclexta Venclexta Starting Pack PA Age Other Prescribed by, or in consultation with an Oncologist or Hematologist. 178

179 VENTAVIS_NVT_2018 Ventavis PA Age Other Diagnosis confirmed by right heart catheterization. Prescribed by, or in consultation with a Pulmonologist or Cardiologist. 179

180 VERZENIO Verzenio PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D None BREAST CANCER (1) Patient must have a diagnosis of advanced or metastatic breast cancer AND (2a) must be used in combination with fulvestrant for the treatment of disease progression following endocrine therapy OR (2b) used as monotherapy for treatment of disease progression following endocrine therapy and patient has already received at least one prior chemotherapy regimen of Ibrance or Kisqali OR (2c) used as initial endocrine-based treatment in combination with an aromatase inhibitor AND (3) disease is hormone receptor positive AND human epidermal growth factor 2 (HER2)- negative 18 years of age or older Prescribed by or in consultation with an oncologist 12 months Approve for continuation of therapy 180

181 VORICONAZOLE_NVT_2018 Voriconazole Intravenous Voriconazole Oral PA Age Other Prescribed by, or in consultation with an Infectious Disease Physician or Oncologist. Approved for 6 months subject to formulary change and member eligibility. 181

182 VOTRIENT_NVT_2018 Votrient PA Age Other Prescribed by, or in consultation with an Oncologist. 182

183 VYXEOS Vyxeos PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Women who are preganant or breastfeeding, anthracycline hypersensitivity Diagnosis of therapy related acute myeloid leukemia or acute myeloid leukemia with myelodysplasia related changes. If the patient has the diagnosis of therapy related acute myeloid leukemia, it must be newly diagnosed. age 18 years and older Prescribed by or in consultation with an oncologist 12 months BvD determination 183

184 XALKORI_NVT_2018 Xalkori PA Age Other Prescribed by, or in consultation with an Oncologist. 184

185 XGEVA_NVT_2018 Xgeva PA Age Other 185

186 XOLAIR_NVT_2018 Xolair PA 1. If for moderate to severe persistent asthma: There must be objective evidence of reversible airway obstruction AND the patient's lge level must be between 30 IU/ml and 700 IU/ml, AND the patient must have a positive skin test or RAST test for specific allergic sensitivity and one of the following: Inadequately controlled asthma despite medium dose of inhaled corticosteroids for at least 3 months in combination with a trial of long-acting inhaled beta-agonists OR a leukotriene modifier and systemic steroids OR high dose inhaled corticosteroids are required to maintain adequate asthma control OR intolerance or contradindication to the previously listed drugs. 2. If for chronic idiopathic urticaria, patient remains symptomatic despite H1 antihistamine treatment or has intolerance or contraindication to H1 antihistamine treatment. Age If for moderate to severe persistent asthma, patient must be at least 6 years old. If for chronic idiopathic urticaria, patient must be at least 12 years old. Other Prescribed by, or in consultation with an Allergy Specialist, Pulmonary Specialist, Dermatology Specialist or Immunologist. 186

187 XTANDI_NVT_2018 Xtandi PA Age Other Failure of or intolerance to abiraterone (Zytiga). Prescribed by, or in consultation with an Oncologist or Urologist. 187

188 XYREM_NVT_2018 Xyrem PA Age Other Prescribed by, or in consultation with a Neurologist, Pulmonologist, or Sleep Medicine Physician. 188

189 YERVOY_NVT_2018 Yervoy Intravenous Solution 50 MG/10ML PA Age Other Prescribed by, or in consultation with an Oncologist or Dermatologist. 189

190 YONDELIS_NVT_2018 Yondelis PA Age Other Prescribed by, or in consultation with an Oncologist. 190

191 YONSA Yonsa PA Covered Uses Age Other All medically accepted indications not otherwise excluded from Part D Pregnancy A) Diagnosis of metastatic castration-resistant prostate cancer, and used in combination with methylprednisolone, Documented history of trial with inadequate treatment response, adverse event, or contraindication to Zytiga None Prescribed by or in consultation with an oncologist 12 months None 191

192 ZALTRAP_NVT_2018 Zaltrap Intravenous Solution 100 MG/4ML PA Age Other Prescribed by, or in consultation with an Oncologist. 192

193 ZAVESCA_NVT_2018 Miglustat Zavesca PA Age Other Prescribed by, or in consultation with a Geneticist, Hematologist, or Metabolic Physician. 193

194 ZEJULA_NVT_2018 Zejula PA Age Other Prescribed by, or in consultation with an Oncologist. 194

195 ZELBORAF_NVT_2018 Zelboraf PA Age Other Prescribed by, or in consultation with an Oncologist. 195

196 ZEPATIER_NVT_2018 Zepatier PA Age Other 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments. Member must be 18 years of age or older. Prescribed by, or in consultation with a Gastroenterologist, Hepatologist, Infectious Disease Physician or Transplant Physician. duration of 12 to 16 weeks. Applied consistent with current AASLD-IDSA guidance. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. 196

197 ZOLINZA_NVT_2018 Zolinza PA Age Other Prescribed by, or in consultation with an Oncologist or Dermatologist. 197

198 ZOSTAVAX_NVT_2018 Zostavax Subcutaneous Suspension Reconstituted PA Age Other PA not required for members 50 and older. 198

199 ZYDELIG_NVT_2018 Zydelig PA Age Other DIAGNOSIS A: Patient has relapsed CLL, defined as CLL progression less than 24 months since the completion of the last prior therapy AND idelalisib (ZYDELIG) will be used in combination with rituximab (RITUXAN). DIAGNOSIS B and C: Patient has relapsed follicular B- cell non-hodgkin lymphoma (FL) OR Patient has relapsed small lymphocytic lymphoma (SLL) AND Patient has received at least two (2) prior systemic therapies. Prescribed by, or in consultation with an Oncologist. 199

200 ZYKADIA_NVT_2018 Zykadia PA Age Other Prescribed by, or in consultation with an Oncologist. 200

201 ZYTIGA_NVT_2018 Zytiga Oral Tablet 250 MG, 500 MG PA Age Other Prescribed by, or in consultation with an Oncologist or Urologist. 201

202 ZYVOX_NVT_2018 Linezolid Intravenous Solution 600 MG/300ML Linezolid Oral PA Age Other Prescribed by, or in consultation with an Infectious Disease Specialist. Approved for 6 months subject to formulary change and member eligibility. 202

203 PART B VERSUS PART D Abelcet Intravenous Suspension 5 MG/ML Acetylcysteine Inhalation Solution 10 %, 20 % Acyclovir Sodium Intravenous Solution 50 MG/ML Adriamycin Intravenous Solution 2 MG/ML Adrucil Intravenous Solution 500 MG/10ML Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, (5 MG/ML) 0.5%, 0.63 MG/3ML, 1.25 MG/3ML AmBisome Intravenous Suspension Reconstituted 50 MG Aminosyn II Intravenous Solution 10 %, 8.5 % Aminosyn II/Electrolytes Intravenous Solution 8.5 % Aminosyn/Electrolytes Intravenous Solution 7 %, 8.5 % Aminosyn-HBC Intravenous Solution 7 % Aminosyn-PF Intravenous Solution 10 %, 7 % Aminosyn-RF Intravenous Solution 5.2 % Amphotericin B Injection Solution Reconstituted 50 MG Aprepitant Oral Capsule 125 MG, 40 MG, 80 & 125 MG, 80 MG Aranesp (Albumin Free) Injection Solution 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML Aranesp (Albumin Free) Injection Solution Prefilled Syringe 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML Argatroban Intravenous Solution 125 MG/125ML Astagraf XL Oral Capsule Extended Release 24 Hour 0.5 MG, 1 MG, 5 MG Atgam Intravenous Injectable 50 MG/ML 203 Azasan Oral Tablet 100 MG, 75 MG AzaTHIOprine Oral Tablet 50 MG AzaTHIOprine Sodium Injection Solution Reconstituted 100 MG Bleomycin Sulfate Injection Solution Reconstituted 30 UNIT Bortezomib Intravenous Solution Reconstituted 3.5 MG Brovana Inhalation Nebulization Solution 15 MCG/2ML Budesonide Inhalation Suspension 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML Calcitriol Intravenous Solution 1 MCG/ML Calcitriol Oral Capsule 0.25 MCG, 0.5 MCG Calcitriol Oral Solution 1 MCG/ML Cladribine Intravenous Solution 10 MG/10ML Clinimix E/Dextrose (2.75/10) Intravenous Solution 2.75 % Clinimix E/Dextrose (2.75/5) Intravenous Solution 2.75 % Clinimix E/Dextrose (4.25/10) Intravenous Solution 4.25 % Clinimix E/Dextrose (4.25/25) Intravenous Solution 4.25 % Clinimix E/Dextrose (4.25/5) Intravenous Solution 4.25 % Clinimix E/Dextrose (5/15) Intravenous Solution 5 % Clinimix E/Dextrose (5/20) Intravenous Solution 5 % Clinimix E/Dextrose (5/25) Intravenous Solution 5 % Clinimix/Dextrose (4.25/10) Intravenous Solution 4.25 % Clinimix/Dextrose (4.25/20) Intravenous Solution 4.25 % Clinimix/Dextrose (4.25/25) Intravenous Solution 4.25 %