2019 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS

2019 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ABILIFY MAINTENA... 49 ABILIFY MYCITE... 49 ABILIFY tablet... 49 abiraterone 250 mg tablet... 405 ABRAXANE... 260 ABSTRAL... 179 ACTEMRA... 85 ACTEMRA ACTPEN... 85 ACTIMMUNE... 28 ACTIQ... 180 ADASUVE... 49 ADCIRCA... 378 ADEMPAS... 380 AFINITOR... 405 AFINITOR DISPERZ... 405 AIMOVIG... 29 AJOVY... 31 ALDARA... 257 ALECENSA... 405 ALIMTA... 260 ALIQOPA... 260 alprazolam ER tablet... 63 Updated 08/2019 COMPLETE 2019 1

ALPRAZOLAM INTENSOL... 63 alprazolam ODT... 63 alprazolam tablet... 63 ALUNBRIG... 405 AMBIEN... 248 AMBIEN CR... 249 ambrisentan tablet... 384 AMITIZA... 37 amitriptyline tablet... 244 AMOXAPINE... 244 AMPYRA... 155 AMRIX... 241 ANADROL-50... 40 ANAFRANIL... 244 ANDRODERM... 47 ANDROGEL 1%... 47 ANDROGEL 1.62%... 47 ANDROXY... 46 APOKYN... 52 ARALAST NP... 33 ARANESP... 167 ARCALYST... 53 aripiprazole ODT... 49 aripiprazole solution, tablet... 49 ARISTADA... 49 ARISTADA INITIO... 49 Updated 08/2019 COMPLETE 2019 2

armodafinil tablet... 54 ARZERRA... 260 ATIVAN tablet... 77 AUBAGIO... 291 AURYXIA... 58 AUSTEDO... 59 AVASTIN... 260 AVEED... 41 AVONEX... 292 AVONEX PREFILLED KIT... 292 AXIRON... 47 BALVERSA... 405 BAVENCIO... 323 BELBUCA... 333 BELEODAQ... 260 BENLYSTA... 61 BENTYL... 238 benztropine tablet... 238 BERINERT... 224 BESPONSA... 260 BETASERON... 293 bexarotene capsule... 405 BIVIGAM... 131 BLINCYTO... 260 BORTEZOMIB... 260 bosentan tablet... 382 Updated 08/2019 COMPLETE 2019 3

BOSULIF... 405 BOTOX... 134 BRAFTOVI... 405 BRISDELLE... 244 BUPHENYL... 450 buprenorphine transdermal patch... 333 butalbital/acetaminophen/caffeine/codeine 50-300-40-30 mg capsule... 238 butalbital/acetaminophen/caffeine/codeine 50-325-40-30 mg capsule... 238 butalbital/aspirin/caffeine/codeine 50-325-40-30 mg capsule... 238 BUTRANS... 333 CABOMETYX... 405 CALQUENCE... 405 CAPRELSA... 405 CARBAGLU... 139 carbinoxamine solution, tablet... 238 CARIMUNE NF... 140 carisoprodol tablet... 240 carisoprodol/aspirin tablet... 240 carisoprodol/aspirin/codeine tablet... 240 CEQUA... 330 CERDELGA... 428 CEREZYME... 194 CHENODAL... 143 chlordiazepoxide capsule... 65 CHLORDIAZEPOXIDE/AMITRIPTYLINE tablet... 67 CHLORPROMAZINE injection... 49 Updated 08/2019 COMPLETE 2019 4

chlorpromazine tablet... 49 CHORIONIC GONADOTROPIN... 144 CIALIS 2.5 mg, 5 mg tablet... 60 CIMZIA... 87 cinacalcet tablet... 145 CINRYZE... 226 CLEMASTINE tablet... 238 clobazam suspension, tablet... 79 clomipramine capsule... 244 clonazepam ODT... 69 clonazepam tablet... 69 clorazepate tablet... 71 clozapine ODT... 49 clozapine tablet... 49 CLOZARIL... 49 COGENTIN... 238 COMETRIQ... 405 CONZIP... 349 COPAXONE... 295 COPIKTRA... 405 CORLANOR... 146 COSENTYX... 89 COTELLIC... 405 CRESEMBA... 147 CRINONE... 148 CRYSVITA... 149 Updated 08/2019 COMPLETE 2019 5

cyclobenzaprine ER capsule... 241 cyclobenzaprine tablet... 241 cyproheptadine syrup, tablet... 238 CYRAMZA... 260 CYSTAGON... 151 DAKLINZA... 153 dalfampridine ER tablet... 155 DALIRESP... 156 danazol capsule... 38 DARZALEX... 260 DAURISMO... 405 deferasirox tablet... 265 DEMEROL 100 mg tablet... 238 DEPO-TESTOSTERONE... 42 desipramine tablet... 244 DESOXYN... 287 DIAZEPAM 1 mg/ml oral solution... 73 diazepam intensol concentrate... 73 diazepam tablet... 73 diclofenac 1% gel... 443 DICLOFENAC 1.3% patch... 441 diclofenac 1.5% solution... 442 dicyclomine capsule, injection, solution, tablet... 238 diphenoxylate/atropine 2.5-0.025 mg tablet... 238 DIPHENOXYLATE/ATROPINE 2.5-0.025 mg/5 ml liquid... 238 disopyramide capsule... 238 Updated 08/2019 COMPLETE 2019 6

DOPTELET... 157 DOXEPIN 5% cream... 440 doxepin capsule, oral concentrate... 244 DOXIL... 260 doxorubicin liposomal injection... 260 DUPIXENT... 158 DURAGESIC... 335 DYSPORT... 136 EDLUAR... 242 EGRIFTA... 160 ELELYSO... 196 ELIDEL... 55 EMBEDA... 341 EMFLAZA... 161 EMGALITY... 162 EMPLICITI... 260 ENBREL... 91 EPCLUSA... 164 EPIDIOLEX... 166 EPOGEN... 169 ERBITUX... 260 ERIVEDGE... 405 ERLEADA... 405 erlotinib tablet... 405 ESBRIET... 262 estazolam tablet... 75 Updated 08/2019 COMPLETE 2019 7

eszopiclone tablet... 243 EUCRISA... 56 EXALGO... 339 EXJADE... 265 EXONDYS 51... 174 EXTAVIA... 293 FANAPT... 49 FANAPT TITRATION PACK... 49 FARYDAK... 405 FASENRA... 175 FAZACLO ODT... 49 fentanyl citrate oral lozenge... 180 fentanyl transdermal patch... 335 FENTORA... 181 FEXMID... 241 FIORICET/CODEINE... 238 FIORINAL/CODEINE #3... 238 FIRAZYR... 228 FIRDAPSE... 183 FLEBOGAMMA... 131 FLECTOR... 441 FLUPHENAZINE concentrate, elixir, injection... 49 fluphenazine decanoate 25 mg/ml injection... 49 fluphenazine tablet... 49 FLURAZEPAM... 76 FOLOTYN... 260 Updated 08/2019 COMPLETE 2019 8

FORTEO... 184 FORTESTA... 47 GALAFOLD... 186 GAMASTAN S/D... 188 GAMMAGARD... 190 GAMMAGARD SD... 190 GAMMAKED... 190 GAMMAPLEX... 131 GAMUNEX-C... 190 GATTEX... 193 GAZYVA... 260 GENOTROPIN... 200 GENOTROPIN MINIQUICK... 200 GEODON... 49 GILENYA 0.5 mg capsule... 294 GILOTRIF... 405 GLASSIA... 34 glatiramer injection... 295 GLEEVEC... 405 GOCOVRI... 35 GRASTEK... 351 H.P. ACTHAR GEL... 26 HAEGARDA... 230 HALAVEN... 260 HALCION... 83 HALDOL... 49 Updated 08/2019 COMPLETE 2019 9

HALDOL DECANOATE... 49 haloperidol concentrate, injection, tablet... 49 haloperidol decanoate injection... 49 HARVONI... 236 HERCEPTIN... 260 HERCEPTIN HYLECTA... 260 HETLIOZ... 237 HEXALEN... 405 HUMATROPE... 203 HUMATROPE COMBO PACK... 203 HUMIRA... 93 HUMIRA KIT... 93 hydromorphone ER tablet... 339 HYDROXYZINE HCL injection... 238 hydroxyzine hcl syrup, tablet... 238 HYDROXYZINE PAMOATE 100 mg capsule... 238 hydroxyzine pamoate 25 mg, 50 mg capsule... 238 HYSINGLA ER... 337 IBRANCE... 405 icatibant 30 mg/3 ml injection... 228 ICLUSIG... 405 IDHIFA... 405 ILARIS... 255 ILUMYA... 95 imatinib mesylate tablet... 405 IMBRUVICA... 405 Updated 08/2019 COMPLETE 2019 10

IMFINZI... 324 imipramine hcl tablet... 244 imipramine pamoate capsule... 244 imiquimod 5% cream... 257 IMIQUIMOD PUMP 3.75%... 468 INBRIJA... 258 INFLECTRA... 97 INFUGEM... 260 INGREZZA... 259 INLYTA... 405 INTERMEZZO... 250 INTUNIV... 238 INVEGA... 49 INVEGA SUSTENNA... 49 INVEGA TRINZA... 49 IRESSA... 405 ISTODAX... 260 JADENU... 266 JADENU SPRINKLE... 266 JAKAFI... 405 JEVTANA... 260 JUXTAPID... 251 JYNARQUE... 267 KADCYLA... 260 KADIAN... 341 KALYDECO... 269 Updated 08/2019 COMPLETE 2019 11

KEVEYIS... 271 KEVZARA... 99 KEYTRUDA... 325 KINERET... 101 KISQALI... 405 KISQALI FEMARA CO PACK... 405 KLONOPIN... 69 KORLYM... 272 KUVAN... 273 KYNAMRO... 253 KYPROLIS... 260 LARTRUVO... 260 LATUDA... 49 LAZANDA... 178 LENVIMA... 405 LETAIRIS... 384 LIBTAYO... 326 lidocaine 2% gel... 274 lidocaine 4% solution... 277 lidocaine 5% ointment... 275 lidocaine 5% transdermal patch... 276 lidocaine/prilocaine 2.5-2.5% cream... 278 LIDODERM... 276 linezolid suspension, tablet... 280 LINZESS... 282 LOMOTIL... 238 Updated 08/2019 COMPLETE 2019 12

LONSURF... 405 lorazepam concentrate, tablet... 77 LORBRENA... 405 loxapine capsule... 49 LUMOXITI... 260 LUNESTA... 243 LYNPARZA... 405 MATULANE... 405 MAVENCLAD... 296 MAVYRET... 283 MAYZENT... 298 MEGACE... 244 MEGACE ES... 244 megestrol suspension, tablet... 244 MEKINIST... 405 MEKTOVI... 405 memantine ER capsule... 286 memantine solution, tablet... 286 memantine titration pak... 286 MEPERIDINE 50 mg/5 ml solution... 238 meperidine tablet... 238 methamphetamine 5 mg tablet... 287 METHITEST... 46 METHYLTESTOSTERONE 10 mg capsule... 46 miglustat 100 mg capsule... 430 MIRCERA... 171 Updated 08/2019 COMPLETE 2019 13

modafinil tablet... 288 MOLINDONE... 49 morphine sulfate ER tablet, capsule... 341 MOTEGRITY... 289 MOVANTIK... 290 MS CONTIN... 341 MULPLETA... 305 MYALEPT... 306 MYLOTARG... 260 NAMENDA... 286 NAMENDA TITRATION PAK... 286 NAMENDA XR... 285 NAMENDA XR TITRATION PAK... 285 NATESTO... 47 NATPARA... 308 NERLYNX... 405 NEXAVAR... 405 NINLARO... 405 NOCDURNA... 310 NOCTIVA... 311 NORDITROPIN FLEXPRO... 206 NORPACE... 238 NORPACE CR... 238 NORPRAMIN... 244 NORTHERA... 312 nortriptyline capsule... 244 Updated 08/2019 COMPLETE 2019 14

NORTRIPTYLINE solution... 244 NOVAREL... 144 NOXAFIL... 314 NUCALA... 316 NUCYNTA ER... 347 NUEDEXTA... 319 NUPLAZID... 320 NUTROPIN AQ NUSPIN... 209 NUVIGIL... 54 OCALIVA... 321 OCTAGAM... 131 octreotide injection... 414 ODOMZO... 405 OFEV... 263 olanzapine injection, tablet... 49 olanzapine ODT... 49 olanzapine/fluoxetine capsule... 49 OLUMIANT... 103 OMNITROPE... 212 ONFI... 79 ONIVYDE... 260 OPDIVO... 327 OPSUMIT... 386 ORALAIR... 353 ORENCIA... 105 ORENITRAM... 388 Updated 08/2019 COMPLETE 2019 15

ORILISSA... 359 ORKAMBI... 357 orphenadrine ER tablet... 246 orphenadrine injection... 246 OSMOLEX ER... 36 OTEZLA... 360 oxandrolone tablet... 39 oxazepam capsule... 80 OXERVATE... 362 OXYCODONE ER... 343 OXYCONTIN... 343 OXYMORPHONE ER... 345 paliperidone ER tablet... 49 PALYNZIQ... 363 PAMELOR... 244 PANZYGA... 365 paroxetine ER tablet... 244 paroxetine tablet... 244 PAXIL... 244 PAXIL CR... 244 PEGASYS... 368 PEGASYS PROCLICK... 368 PENNSAID... 442 pentazocine/naloxone tablet... 238 PERJETA... 260 perphenazine tablet... 49 Updated 08/2019 COMPLETE 2019 16

PERSERIS... 49 PEXEVA... 244 PHENERGAN... 238 pimecrolimus 1% cream... 55 PIQRAY... 406 PLEGRIDY... 299 PLEGRIDY STARTER PACK... 299 POLIVY... 260 POMALYST... 406 PORTRAZZA... 260 POTELIGEO... 260 PRALUENT... 369 PREGNYL... 144 PRIVIGEN... 131 PROCRIT... 169 PROCYSBI... 152 PROLASTIN-C... 33 PROLIA... 372 PROMACTA... 375 promethazine injection, suppository, syrup, tablet... 238 PROMETHAZINE/PHENYLEPHRINE syrup... 238 PROPANTHELINE 15 mg tablet... 238 PROTOPIC... 57 protriptyline tablet... 244 PROVIGIL... 288 PRUDOXIN... 440 Updated 08/2019 COMPLETE 2019 17

QUALAQUIN... 396 quetiapine ER tablet... 49 quetiapine tablet... 49 quinine sulfate capsule... 396 RADICAVA... 397 RAGWITEK... 355 RAVICTI... 451 RAYOS... 398 REBIF... 300 REBIF REBIDOSE... 300 REBIF REBIDOSE TITRATION PACK... 300 REBIF TITRATION PACK... 300 REGRANEX... 399 RELISTOR... 400 REMICADE... 107 RENFLEXIS... 109 REPATHA... 401 RESTASIS... 331 RESTASIS MULTIDOSE... 331 RESTORIL... 82 RETACRIT... 172 REVATIO... 390 REVLIMID... 406 REXULTI... 49 RISPERDAL... 49 RISPERDAL CONSTA... 49 Updated 08/2019 COMPLETE 2019 18

RISPERDAL M-TAB 2 mg... 49 risperidone ODT... 49 risperidone solution, tablet... 49 RITUXAN... 111 RITUXAN HYCELA... 113 ROMIDEPSIN... 260 RUBRACA... 406 RUCONEST... 232 RYCLORA... 238 RYDAPT... 406 SAIZEN... 215 SAIZEN CLICK.EASY... 215 SAIZENPREP RECONSTITUTION KIT... 215 SAMSCA... 404 SANDOSTATIN... 414 SANDOSTATIN LAR... 416 SAPHRIS... 50 scopolamine patch... 238 SENSIPAR... 145 SEROQUEL... 50 SEROQUEL XR... 50 SEROSTIM... 218 SIGNIFOR... 410 SIGNIFOR LAR... 408 sildenafil injection, suspension, 20 mg tablet... 390 SILIQ... 115 Updated 08/2019 COMPLETE 2019 19

SIMPONI... 117 SIMPONI ARIA... 119 SIVEXTRO tablet... 412 SKYRIZI... 121 sodium phenylbutyrate powder, tablet... 450 SOMA... 240 SOMATULINE DEPOT... 418 SOMAVERT... 420 SONATA... 247 SOVALDI... 422 SPRAVATO... 424 SPRYCEL... 406 STELARA... 123 STIVARGA... 406 STRENSIQ... 426 STRIANT... 47 SUBSYS... 182 SURMONTIL... 244 SUTENT... 406 SYLATRON... 406 SYMBYAX... 50 SYMDEKO... 432 SYMPAZAN... 84 SYMPROIC... 434 SYNRIBO... 260 SYPRINE... 445 Updated 08/2019 COMPLETE 2019 20

tacrolimus ointment... 57 tadalafil 2.5 mg, 5 mg tablet... 60 tadalafil 20 mg tablet (generic for Adcirca)... 378 TAFINLAR... 406 TAGRISSO... 406 TAKHZYRO... 234 TALTZ... 125 TALZENNA... 406 TARCEVA... 406 TARGRETIN... 406 TASIGNA... 406 TAVALISSE... 435 TECENTRIQ... 328 TECFIDERA... 302 TECFIDERA STARTER PACK... 302 TECHNIVIE... 436 TEGSEDI... 438 temazepam capsule... 82 TENCON... 238 TESTIM... 47 testosterone 1% gel... 47 testosterone 1.62% gel... 47 testosterone 10 mg/act gel... 47 testosterone 30 mg/actuation solution... 47 testosterone cypionate injection... 42 testosterone enanthate injection... 44 Updated 08/2019 COMPLETE 2019 21

tetrabenazine tablet... 439 THALOMID... 406 thioridazine tablet... 50 thiothixene capsule... 50 TIBSOVO... 406 TOFRANIL... 244 TRACLEER... 382 TRAMADOL ER capsule... 349 tramadol ER tablet... 349 TRANSDERM-SCOP... 238 TRANXENE T... 71 TRELSTAR... 444 TRELSTAR MIXJECT... 444 TREMFYA... 127 tretinoin capsule... 406 triazolam tablet... 83 trientine capsule... 445 trifluoperazine tablet... 50 trihexyphenidyl elixir, tablet... 238 trimipramine capsule... 244 TYKERB... 406 TYMLOS... 447 TYSABRI... 303 UNITUXIN... 260 UPTRAVI... 392 VALIUM... 73 Updated 08/2019 COMPLETE 2019 22

VECTIBIX... 260 VELCADE... 260 VENCLEXTA... 406 VENCLEXTA STARTING PACK... 406 VENTAVIS... 394 VERSACLOZ... 50 VERZENIO... 406 VFEND... 456 VFEND IV... 456 VIEKIRA PAK... 452 VIEKIRA XR... 454 VISTARIL... 238 VITRAKVI... 406 VIZIMPRO... 406 VOGELXO... 47 VOGELXO PUMP... 47 VOLTAREN 1% gel... 443 voriconazole injection, suspension, tablet... 456 VOSEVI... 458 VOTRIENT... 406 VPRIV... 198 VRAYLAR... 50 VYXEOS... 261 XALKORI... 406 XANAX... 63 XANAX XR... 63 Updated 08/2019 COMPLETE 2019 23

XELJANZ... 129 XELJANZ XR... 129 XENAZINE... 439 XEOMIN... 137 XERMELO... 459 XGEVA... 460 XIIDRA... 332 XOLAIR... 462 XOSPATA... 406 XTAMPZA ER... 343 XTANDI... 406 XYOSTED... 45 XYREM... 465 YERVOY... 329 YONDELIS... 261 YONSA... 406 zaleplon capsule... 247 ZALTRAP... 261 ZAVESCA... 430 ZEJULA... 406 ZELBORAF... 406 ZEMAIRA... 33 ZEPATIER... 466 ziprasidone capsule... 50 ZOHYDRO ER... 337 ZOLINZA... 406 Updated 08/2019 COMPLETE 2019 24

zolpidem ER tablet... 249 zolpidem sublingual tablet... 250 zolpidem tablet... 248 ZOMACTON... 220 ZONALON... 440 ZORBTIVE... 223 ZTLIDO... 279 ZURAMPIC... 449 ZYCLARA... 468 ZYCLARA PUMP... 468 ZYDELIG... 406 ZYKADIA... 406 ZYPREXA... 50 ZYPREXA RELPREVV... 50 ZYPREXA ZYDIS... 50 ZYTIGA... 406 ZYVOX suspension, tablet... 280 Updated 08/2019 COMPLETE 2019 25

Prior Authorization Group Acthar HP Gel PA H.P. ACTHAR GEL All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require BOTH of the following: 1. ONE of the following: a. Patient has a diagnosis of infantile spasm OR b. Patient has a diagnosis of nephrotic syndrome AND ONE of the following: i. Patient has failed a conventional agent (i.e. prednisone, cyclophosphamide, tacrolimus) for the requested indication OR ii. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to a conventional agent OR c. Patient has a diagnosis of multiple sclerosis AND ALL of the following: i. Patient is experiencing an acute exacerbation AND ii. If indicated, there is evidence of a claim that the patient is currently on a disease modifying drug (DMD) within the past 90 days (e.g. Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer (i.e. Copaxone, Glatopa), Lemtrada, mitoxantrone, Ocrevus, Plegridy, Rebif, Tecfidera, or Tysabri) to control disease progression OR has a documented intolerance, FDA labeled contraindication, or hypersensitivity to a DMD AND iii. Patient has failed corticosteroid therapy within the last 30 days or has an FDA labeled contraindication to corticosteroid therapy (e.g. methylprednisolone 1gm IV for 3-5 days) OR Criteria continues: see Other Criteria For diagnosis of infantile spasm, patient is less than 24 months of age. For diagnosis of nephrotic syndrome, patient is greater than 2 years of age. 6 months for infantile spasm, 1 month for all other indications Updated 08/2019 COMPLETE 2019 26

d. Patient has a diagnosis of rheumatic disorder (e.g. ankylosing spondylitis, juvenile idiopathic arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, rheumatoid arthritis) AND BOTH of the following: i. If indicated, there is evidence of a claim that the patient is currently being treated with a conventional agent within the past 90 days (e.g. DMARD [methotrexate, leflunomide], biologics [Humira, Enbrel]) to control disease progression OR has a documented intolerance, FDA labeled contraindication, or hypersensitivity to a conventional agent AND ii. Patient has failed corticosteroid therapy within the last 30 days or has an FDA labeled contraindication to corticosteroid therapy (e.g. methylprednisolone 1gm IV for 3-5 days) OR e. Patient has a diagnosis of systemic lupus erythematosus (SLE) disease AND ALL of the following: i. Patient has a history of positive antinuclear antibody (ANA) and/or positive anti-dsdna results AND ii. Patient has a history of 3 other SLE diagnostic criteria (i.e. malar rash, discoid rash, photosensitivity, oral ulcers, nonerosive arthritis, serositis [e.g. pleuritis/pericarditis], renal disorder [e.g. persistent proteinuria greater than 0.5 grams/day or cellular casts], hematologic disorder [e.g. hemolytic anemia (with reticulocytosis), leukopenia, lymphopenia, or thrombocytopenia], and/or immunologic disorder [e.g. positive finding of antiphospholipid antibodies or anti-sm antibodies]) AND iii. ONE of the following: 1. There is evidence of a claim that the patient is currently on a SLE treatment regimen within the past 90 days comprised of at least ONE of the following: corticosteroids (e.g. methylprednisolone, prednisone), antimalarials (e.g. hydroxychloroquine, chloroquine), prescription nonsteroidal anti-inflammatory drugs (NSAIDS) (e.g. ibuprofen, naproxen), and/or immunosuppressive (e.g. azathioprine, methotrexate, cyclosporine, or oral cyclophosphamide) OR 2. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to any standard of care drug class listed above OR f. Patient has another FDA approved indication AND i. Patient has failed corticosteroid therapy within the last 30 days or has an FDA labeled contraindication to corticosteroids therapy (e.g. methylprednisolone 1gm IV for 3-5 days) OR g. Patient has another indication that is supported in CMS approved compendia for the requested agent AND i. Patient has failed corticosteroid therapy within the last 30 days or has an FDA labeled contraindication to corticosteroids therapy (e.g. methylprednisolone 1gm IV for 3-5 days) AND 2. The dose is within the FDA labeled or CMS approved compendia dosing for the requested indication Updated 08/2019 COMPLETE 2019 27

Prior Authorization Group Actimmune PA ACTIMMUNE All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. This program applies to new starts only. Criteria for approval require BOTH of the following: 1. ONE of the following: a. Patient has an FDA labeled indication for the requested agent OR b. Patient has an indication that is supported in CMS approved compendia for the requested agent AND 2. The dose requested is within the FDA labeled or CMS approved compendia dosing for the requested indication Approval will be for 12 months Updated 08/2019 COMPLETE 2019 28

Prior Authorization Group Aimovig PA AIMOVIG All FDA-approved indications not otherwise excluded from Part D. Criteria for initial approval require ALL of the following: 1. Patient has a diagnosis of migraine AND 2. Patient has 4 migraine headaches or more per month AND 3. ONE of the following: a. Patient has failed at least TWO conventional migraine prophylaxis agents from TWO different classes (e.g. beta blockers [propranolol], anticonvulsants [divalproex, topiramate]) OR b. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to TWO conventional migraine prophylaxis agents from TWO different classes AND 4. ONE of the following: a. Patient is NOT currently taking another calcitonin gene-related peptide (CGRP) agent OR b. Patient is currently being treated with another calcitonin gene-related peptide (CGRP) agent AND will discontinue prior to initiating therapy with the requested agent Criteria for renewal approval require ALL of the following: 1. Patient has been previously approved for the requested agent through the plan s prior authorization criteria AND 2. Patient has a diagnosis of migraine AND 3. Patient has shown clinical benefit with the requested agent AND 4. ONE of the following: a. Patient is NOT currently taking another calcitonin gene-related peptide (CGRP) agent OR b. Patient is currently being treated with another calcitonin gene-related peptide (CGRP) agent AND will discontinue prior to continuing therapy with the requested agent Updated 08/2019 COMPLETE 2019 29

Approval will be for 12 months Updated 08/2019 COMPLETE 2019 30

Prior Authorization Group Ajovy PA AJOVY All FDA-approved indications not otherwise excluded from Part D. Criteria for initial approval require ALL of the following: 1. Patient has a diagnosis of migraine AND 2. Patient has 4 migraine headaches or more per month AND 3. ONE of the following: a. Patient has failed at least TWO conventional migraine prophylaxis agents from TWO different classes (e.g. beta blockers [propranolol], anticonvulsants [divalproex, topiramate]) OR b. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to TWO conventional migraine prophylaxis agents from TWO different classes AND 4. ONE of the following: a. Patient is NOT currently taking another calcitonin gene-related peptide (CGRP) agent OR b. Patient is currently being treated with another calcitonin gene-related peptide (CGRP) agent AND will discontinue prior to initiating therapy with the requested agent Criteria for renewal approval require ALL of the following: 1. Patient has been previously approved for the requested agent through the plan s prior authorization criteria AND 2. Patient has a diagnosis of migraine AND 3. Patient has shown clinical benefit with the requested agent AND 4. ONE of the following: a. Patient is NOT currently taking another calcitonin gene-related peptide (CGRP) agent OR b. Patient is currently being treated with another calcitonin gene-related peptide (CGRP) agent AND will discontinue prior to continuing therapy with the requested agent Updated 08/2019 COMPLETE 2019 31

Approval will be for 12 months Updated 08/2019 COMPLETE 2019 32

Prior Authorization Group Alpha-1-Proteinase Inhibitor PA - Aralast/Prolastin- C/Zemaira ARALAST NP PROLASTIN-C ZEMAIRA All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for initial approval require ALL of the following: 1. Patient has a diagnosis of alpha-1 antitrypsin deficiency (AATD) AND 2. Patient has a pre-treatment serum alpha-1 antitrypsin (AAT) level less than 11 µm/l (80 mg/dl by immunodiffusion or 57 mg/dl using nephelometry) AND 3. Patient has one of the following phenotype variants associated with AATD: PiZZ, PiSZ, PiZ/Null or PiNull/Null AND 4. Patient has emphysema with a documented baseline FEV1 of 65% or less of predicted AND 5. The dose requested is within the FDA labeled dose Criteria for renewal approval require ALL of the following: 1. Patient has been previously approved for the requested agent through the plan s PA criteria AND 2. Patient has a diagnosis of alpha-1 antitrypsin deficiency (AATD) with clinically evident emphysema AND 3. Patient has shown clinical benefit with the requested agent AND 4. The dose requested is within the FDA labeled dose Approval will be for 12 months Updated 08/2019 COMPLETE 2019 33

Prior Authorization Group Alpha-1-Proteinase Inhibitor PA - Glassia GLASSIA All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for initial approval require ALL of the following: 1. Patient has a diagnosis of alpha-1 antitrypsin deficiency (AATD) AND 2. Patient has a pre-treatment serum alpha-1 antitrypsin (AAT) level less than 11 µm/l (80 mg/dl by immunodiffusion or 57 mg/dl using nephelometry) AND 3. Patient has one of the following phenotype variants associated with AATD: PiZZ, PiSZ, PiZ/Null or PiNull/Null AND 4. Patient has emphysema with a documented baseline FEV1 of 65% or less of predicted AND 5. The dose requested is within the FDA labeled dose Criteria for renewal approval require ALL of the following: 1. Patient has been previously approved for the requested agent through the plan s PA criteria AND 2. Patient has a diagnosis of alpha-1 antitrypsin deficiency (AATD) with clinically evident emphysema AND 3. Patient has shown clinical benefit with the requested agent AND 4. The dose requested is within the FDA labeled dose Approval will be for 12 months Updated 08/2019 COMPLETE 2019 34

Prior Authorization Group Amantadine ER PA - Gocovri GOCOVRI All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has a diagnosis of Parkinson s disease AND 2. The requested agent will be used for the treatment of dyskinesia AND 3. Patient is currently receiving levodopa-based therapy Prescriber is a specialist (e.g. neurologist) or the prescriber has consulted with a specialist Approval will be for 12 months Updated 08/2019 COMPLETE 2019 35

Prior Authorization Group Amantadine ER PA - Osmolex ER OSMOLEX ER All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ONE of the following: A. Patient has a diagnosis of Parkinson s disease OR B. Patient has a diagnosis of drug-induced extrapyramidal reaction AND the following: i. Prescriber has assessed and adjusted, if applicable, any medications known to cause extrapyramidal symptoms Prescriber is a specialist (e.g. neurologist) or the prescriber has consulted with a specialist Approval will be for 12 months Updated 08/2019 COMPLETE 2019 36

Prior Authorization Group Amitiza PA AMITIZA All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require BOTH of the following: 1. Patient has ONE of the following diagnoses: A. Chronic idiopathic constipation with documentation of symptoms for at least 3 months OR B. Irritable bowel syndrome with constipation with documentation of symptoms for at least 3 months AND the patient is female OR C. Opioid-induced constipation with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment AND BOTH of the following: i. Patient has chronic use of an opioid agent within the past 90 days AND ii. Patient has NOT received methadone within the past 90 days AND 2. ONE of the following: A. Patient has a medication history that includes lactulose or polyethylene glycol 3350 OR B. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to lactulose or polyethylene glycol 3350 Patient is 18 years of age or over Approval will be for 12 months Updated 08/2019 COMPLETE 2019 37

Prior Authorization Group Anabolic Steroid PA - Danazol danazol capsule All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require BOTH of the following: 1. Patient has ONE of the following diagnoses: a. Patient has an FDA labeled indication for the requested agent OR b. Patient has an indication that is supported in CMS approved compendia for the requested agent AND 2. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 38

Prior Authorization Group Anabolic Steroid PA - Oxandrolone oxandrolone tablet All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require BOTH of the following: 1. Patient has ONE of the following diagnoses: a. Patient has AIDS/HIV-associated wasting syndrome (defined as unexplained involuntary weight loss greater than 10% baseline body weight with obvious wasting or body mass index less than 18.5 kg/m2) AND all other causes of weight loss have been ruled out OR b. Patient is a female child or adolescent with Turner syndrome AND is currently receiving growth hormone OR c. Patient has weight loss following extensive surgery, chronic infections, or severe trauma OR d. Patient has chronic pain from osteoporosis OR e. Patient is on long-term administration of oral or injectable corticosteroids AND 2. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 39

Prior Authorization Group Anabolic Steroid PA - Oxymetholone ANADROL-50 All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient has anemia caused by deficient red cell production, including acquired aplastic anemia, congenital aplastic anemia, myelofibrosis and the hypoplastic anemias due to the administration of myelotoxic drugs OR b. Patient has anemia associated with chronic renal failure AND ONE of the following: i. Patient s medication history indicates previous use of an erythropoiesisstimulating agent OR ii. Patient has a documented intolerance, FDA labeled contraindication or hypersensitivity to an erythropoiesis-stimulating agent AND 2. Patient has a hematocrit (Hct) value less than 30% AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 40

Prior Authorization Group Androgen Injectable PA - Aveed AVEED All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient is a male with a diagnosis of primary or secondary (hypogonadotropic) hypogonadism AND 2. Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 41

Prior Authorization Group Androgen Injectable PA - testosterone cypionate DEPO-TESTOSTERONE testosterone cypionate injection All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient is a male with AIDS/HIV-associated wasting syndrome, defined as unexplained involuntary weight loss (greater than 10% baseline body weight) with obvious wasting OR body mass index less than 18.5 kg/m2 AND all other causes of weight loss have been ruled out OR b. Patient is a female with metastatic/inoperable breast cancer OR c. Patient is a male with primary or secondary (hypogonadotropic) hypogonadism OR d. Patient is an adolescent male with delayed puberty AND 2. Males only: Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be 6 months for delayed puberty, 12 months for all other indications Updated 08/2019 COMPLETE 2019 42

Updated 08/2019 COMPLETE 2019 43

Prior Authorization Group Androgen Injectable PA - testosterone enanthate testosterone enanthate injection All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient is a male with AIDS/HIV-associated wasting syndrome, defined as unexplained involuntary weight loss (greater than 10% baseline body weight) with obvious wasting OR body mass index less than 18.5 kg/m2 AND all other causes of weight loss have been ruled out OR b. Patient is a female with metastatic/inoperable breast cancer OR c. Patient is a male with primary or secondary (hypogonadotropic) hypogonadism OR d. Patient is an adolescent male with delayed puberty AND 2. Males only: Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be 6 months for delayed puberty, 12 months for all other indications Updated 08/2019 COMPLETE 2019 44

Prior Authorization Group Androgen Injectable PA - Xyosted XYOSTED All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient is a male with AIDS/HIV-associated wasting syndrome, defined as unexplained involuntary weight loss (greater than 10% baseline body weight) with obvious wasting OR body mass index less than 18.5 kg/m2 AND all other causes of weight loss have been ruled out OR b. Patient is a male with primary or secondary (hypogonadotropic) hypogonadism AND 2. Males only: Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 45

Prior Authorization Group Androgen Oral PA ANDROXY METHITEST METHYLTESTOSTERONE 10 mg capsule All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient is a male with cryptorchidism OR b. Patient is a male with hypogonadism OR c. Patient is an adolescent male with delayed puberty OR d. Patient is a female with metastatic/inoperable breast cancer AND 2. Males only: Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be 6 months for delayed puberty, 12 months for all other indications Updated 08/2019 COMPLETE 2019 46

Prior Authorization Group Androgen Topical PA ANDRODERM ANDROGEL 1% ANDROGEL 1.62% AXIRON FORTESTA NATESTO STRIANT TESTIM testosterone 1% gel testosterone 1.62% gel testosterone 10 mg/act gel testosterone 30 mg/actuation solution VOGELXO VOGELXO PUMP All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. Patient has ONE of the following diagnoses: a. Patient has AIDS/HIV-associated wasting syndrome, defined as unexplained involuntary weight loss (greater than 10% baseline body weight) with obvious wasting OR body mass index less than 18.5 kg/m2 AND all other causes of weight loss have been ruled out OR b. Patient is a male with primary or secondary (hypogonadotropic) hypogonadism AND 2. Males only: Patient has a measured current or pretreatment total serum testosterone level that is below the testing laboratory s lower limit of the normal range or is less than 300 ng/dl OR a free serum testosterone level that is below the testing laboratory s lower limit of the normal range AND 3. ONE of the following: a. Patient is NOT currently treated with another androgen or anabolic steroid within the past 90 days OR b. The current androgen or anabolic steroid will be discontinued prior to starting the requested agent OR Updated 08/2019 COMPLETE 2019 47

c. Prescriber has submitted documentation in support of therapy with more than one agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 48

Prior Authorization Group Antipsychotics PA ABILIFY MAINTENA ABILIFY MYCITE ABILIFY tablet ADASUVE aripiprazole ODT aripiprazole solution, tablet ARISTADA ARISTADA INITIO CHLORPROMAZINE injection chlorpromazine tablet clozapine ODT clozapine tablet CLOZARIL FANAPT FANAPT TITRATION PACK FAZACLO ODT FLUPHENAZINE concentrate, elixir, injection fluphenazine decanoate 25 mg/ml injection fluphenazine tablet GEODON HALDOL HALDOL DECANOATE haloperidol concentrate, injection, tablet haloperidol decanoate injection INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA loxapine capsule MOLINDONE olanzapine injection, tablet olanzapine ODT olanzapine/fluoxetine capsule paliperidone ER tablet perphenazine tablet PERSERIS quetiapine ER tablet quetiapine tablet REXULTI RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB 2 mg risperidone ODT risperidone solution, tablet Updated 08/2019 COMPLETE 2019 49

SAPHRIS SEROQUEL SEROQUEL XR SYMBYAX thioridazine tablet thiothixene capsule trifluoperazine tablet VERSACLOZ VRAYLAR ziprasidone capsule ZYPREXA ZYPREXA RELPREVV ZYPREXA ZYDIS All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Program applies to new starts only. PA does NOT apply to patients less than 65 years of age. Criteria for approval require BOTH of the following: 1. Patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested agent AND 2. ONE of the following: A. There is evidence of a claim that the patient is currently being treated with the requested agent within the past 180 days OR B. Prescriber states the patient is currently using the requested agent OR C. IF dementia-related psychosis, BOTH of the following: i. Dementia-related psychosis is determined to be severe or the associated agitation, combativeness, or violent behavior puts the patient or others in danger AND ii. Prescriber has documented that s/he has discussed the risk of increased mortality with the patient and/or the patient s surrogate decision maker Approval authorizations will apply to the requested medication only. Updated 08/2019 COMPLETE 2019 50

Approval will be for 12 months Updated 08/2019 COMPLETE 2019 51

Prior Authorization Group Apokyn PA APOKYN All FDA-approved indications not otherwise excluded from Part D. Receiving a 5-HT3 antagonist (e.g., ondansetron, granisetron, dolasetron, palonosetron, alosetron) concomitantly with the requested agent Criteria for approval require BOTH of the following: 1. The requested agent will be used to treat acute, intermittent hypomobility, off episodes (muscle stiffness, slow movements, or difficulty starting movement) associated with advanced Parkinson s disease AND 2. There is evidence of a claim that the patient is receiving concurrent therapy for Parkinson s disease (e.g., levodopa, dopamine agonist, or monoamine oxidase B inhibitor) within the past 30 days Prescriber is a neurologist or the prescriber has consulted with a neurologist Approval will be for 12 months Updated 08/2019 COMPLETE 2019 52

Prior Authorization Group Arcalyst PA ARCALYST All FDA-approved indications not otherwise excluded from Part D. An active or chronic infection (e.g. tuberculosis, HIV, hepatitis B/C) Criteria for approval require BOTH of the following: 1. Patient has been diagnosed with Cryopyrin-Associated Periodic Syndromes (CAPS) including Familial Cold Auto-inflammatory Syndrome (FCAS) or Muckle-Wells Syndrome (MWS) AND 2. ONE of the following: A. Patient is NOT currently being treated with another biologic agent OR B. Patient is currently being treated with another biologic agent and the agent will be discontinued prior to initiating the requested agent Patient is at least 12 years of age Approval will be for 12 months Updated 08/2019 COMPLETE 2019 53

Prior Authorization Group Armodafinil PA armodafinil tablet NUVIGIL All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Criteria for approval require BOTH of the following: 1. ONE of the following: A. Patient has an FDA labeled indication for the requested agent OR B. Patient has an indication that is supported in CMS approved compendia for the requested agent AND 2. ONE of the following: A. Patient is receiving only one of the listed agents, armodafinil OR modafinil, within the past 90 days OR B. Patient has been treated with modafinil within the past 90 days AND will discontinue prior to starting the requested agent Patient is 17 years of age or over Approval will be for 12 months Updated 08/2019 COMPLETE 2019 54

Prior Authorization Group Atopic Dermatitis PA - Elidel ELIDEL pimecrolimus 1% cream All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Criteria for approval require ONE of the following: 1. Patient has a diagnosis of atopic dermatitis or vulvar lichen sclerosus AND ONE of the following: A. Patient has had a trial and failure of a topical corticosteroid or topical corticosteroid combination preparation (e.g. clobetasol, hydrocortisone, triamcinolone) OR B. Patient has a documented intolerance, FDA labeled contraindication or hypersensitivity to a topical corticosteroid or topical corticosteroid combination preparation OR 2. Patient has a diagnosis of facial seborrheic dermatitis associated with HIV infection AND BOTH of the following: A. Patient is currently on an antiretroviral treatment regimen AND B. ONE of the following: i. Patient has had a trial and failure of a topical corticosteroid or topical antifungal treatment (e.g. hydrocortisone, triamcinolone, ketoconazole, nystatin-triamcinolone) OR ii. Patient has a documented intolerance, FDA labeled contraindication or hypersensitivity to a topical corticosteroid or topical antifungal treatment OR 3. Patient has an indication that is supported in CMS approved compendia for the requested agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 55

Prior Authorization Group Atopic Dermatitis PA - Eucrisa EUCRISA All FDA-approved indications not otherwise excluded from Part D. Criteria for approval require BOTH of the following: 1. Patient has a diagnosis of atopic dermatitis AND 2. ONE of the following: A. Patient has had a trial and failure with a topical corticosteroid or topical corticosteroid combination preparation (e.g. clobetasol, hydrocortisone, triamcinolone) OR B. Patient has a documented intolerance, FDA labeled contraindication or hypersensitivity to a topical corticosteroid or topical corticosteroid combination preparation Approval will be for 12 months Updated 08/2019 COMPLETE 2019 56

Prior Authorization Group Atopic Dermatitis PA - Tacrolimus PROTOPIC tacrolimus ointment All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Criteria for approval require ONE of the following: 1. Patient has a diagnosis of atopic dermatitis AND ONE of the following: A. Patient has had a trial and failure with a topical corticosteroid or topical corticosteroid combination preparation (e.g. clobetasol, hydrocortisone, triamcinolone) OR B. Patient has a documented intolerance, FDA labeled contraindication or hypersensitivity to a topical corticosteroid or topical corticosteroid combination preparation OR 2. Patient has an indication that is supported in CMS approved compendia for the requested agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 57

Prior Authorization Group Auryxia PA AURYXIA All FDA-approved indications not otherwise excluded from Part D. Requested agent will be used as iron replacement therapy to treat iron deficiency anemia AND FDA labeled contraindication(s) to the requested agent Criteria for approval require the following: 1. Patient has a diagnosis of hyperphosphatemia in chronic kidney disease on dialysis Approval will be for 12 months Updated 08/2019 COMPLETE 2019 58

Prior Authorization Group Austedo PA AUSTEDO All FDA-approved indications not otherwise excluded from Part D. FDA labeled contraindication(s) to the requested agent Criteria for approval require ALL of the following: 1. ONE of the following: A. Patient has a diagnosis of chorea associated with Huntington s disease AND BOTH of the following: i. If the patient has a current diagnosis of depression, the patient is being treated for depression AND ii. If the patient has a diagnosis of passive suicidal ideation, the patient must not be actively suicidal OR B. Patient has a diagnosis of tardive dyskinesia AND ONE of the following: i. Prescriber has reduced the dose of or discontinued any medications known to cause tardive dyskinesia (i.e., dopamine receptor blocking agents) OR ii. Prescriber has provided clinical rationale indicating that a reduced dose or discontinuation of the offending agent is not appropriate AND 2. Patient is NOT receiving a monoamine oxidase inhibitor (MAOI) OR the patient s MAOI will be discontinued at least 14 days before starting therapy with the requested agent AND 3. Patient is NOT receiving reserpine OR the patient s reserpine will be discontinued at least 20 days before starting therapy with the requested agent Approval will be for 12 months Updated 08/2019 COMPLETE 2019 59

Prior Authorization Group Benign Prostatic Hyperplasia PA - Tadalafil CIALIS 2.5 mg, 5 mg tablet tadalafil 2.5 mg, 5 mg tablet All FDA-approved indications not otherwise excluded from Part D. Requested agent will be used to treat erectile dysfunction AND FDA labeled contraindication(s) to the requested agent Criteria for approval require the following: 1. Patient has a diagnosis of benign prostatic hyperplasia (BPH) AND ONE of the following: a. Patient has tried and failed two alpha blocker agents (e.g. terazosin, doxazosin, tamsulosin) OR b. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to two alpha blocker agents (e.g. terazosin, doxazosin, tamsulosin) Approval will be for 12 months Updated 08/2019 COMPLETE 2019 60

Prior Authorization Group Benlysta PA BENLYSTA All FDA-approved indications not otherwise excluded from Part D. Criteria for initial approval require ALL of the following: 1. Patient has a diagnosis of active systemic lupus erythematosus (SLE) disease AND 2. Patient has a history of positive antinuclear antibody (ANA) and/or positive antidsdna results AND 3. Patient has a history of 3 other SLE diagnostic criteria (i.e. malar rash, discoid rash, photosensitivity, oral ulcers, nonerosive arthritis, serositis [e.g. pleuritis/pericarditis], renal disorder [e.g. persistent proteinuria greater than 0.5 grams/day or cellular casts], hematologic disorder [e.g. hemolytic anemia (with reticulocytosis), leukopenia, lymphopenia, or thrombocytopenia], and/or immunologic disorder [e.g. positive finding of antiphospholipid antibodies or anti-sm antibodies]) AND 4. ONE of the following: A. There is evidence of a claim that the patient is currently on SLE treatment regimen within the past 90 days comprised of at least ONE of the following: corticosteroids (e.g. methylprednisolone, prednisone), antimalarials (e.g. hydroxychloroquine, chloroquine), prescription nonsteroidal anti-inflammatory drugs (NSAIDS) (e.g. ibuprofen, naproxen), and/or immunosuppressives (e.g. azathioprine, methotrexate, cyclosporine, or oral cyclophosphamide) OR B. Patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to any standard of care drug classes listed above AND 5. ONE of the following: A. Patient has NOT been treated with intravenous (IV) cyclophosphamide in the past 30 days OR B. Patient has been treated with IV cyclophosphamide in the past 30 days AND will discontinue prior to starting the requested agent AND 6. ONE of the following: A. Patient has NOT been treated with another biologic agent in the past 30 days OR B. Patient has been treated with another biologic agent in the past 30 days AND will discontinue prior to starting the requested agent Updated 08/2019 COMPLETE 2019 61