Ambrisentan (Letairis) Drugs LETAIRIS. Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Pregnancy

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1 Ambrisentan (Letairis) LETAIRIS Pregnancy 1

2 apomorphine (Apokyn) APOKYN 2

3 Apremilast (Otezla) OTEZLA, OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 3

4 Aprepitant (Emend) aprepitant 3 months None 4

5 Chorionic Gonadotropin chorionic gonadotropin, human 5

6 Dalfampridine (Ampyra) AMPYRA 6

7 Daptomycin (Cubicin) daptomycin intravenous recon soln 500 mg Minimum of 2 weeks and may extend up to 6 weeks based on indication. 7

8 Darbepoetin (Aranesp) ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML, ARANESP (IN POLYSORBATE) INJECTION SYRINGE. 6 months 8

9 Denosumab (Prolia) PROLIA 9

10 Dextromethorphan/Quinidine (Nuedexta) NUEDEXTA 10

11 Diclofenac (Solaraze) diclofenac sodium topical gel 3 % 11

12 Diclofenac Epolamine (Flector) FLECTOR 2 weeks 12

13 Dimethyl Fumarate (Tecfidera) TECFIDERA 13

14 Dornase Alfa (Pulmozyme) PULMOZYME 14

15 Droxidopa (Northera) NORTHERA 15

16 Dulaglutide (Trulicity) TRULICITY 16

17 Elbasvir and Grazoprevir (Zepatier) ZEPATIER weeks Criteria will be applied consistent with current AASLD/IDSA guidance. 17

18 eltrombopag (Promacta) PROMACTA 18

19 Empagliflozin (Jardiance) JARDIANCE 19

20 Enoxaparin (Lovenox) enoxaparin reduce frequency with creatinine clearance less than 30 Minimum of 5 days of therapy and may extend up to 35 days unless prescribed for a shorter duration None 20

21 epoetin (Epogen) EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML 6 months 21

22 Epoetin (Procrit) PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML bleeding, autoimmune hemolytic anemia, inufficient vitamin stores, uncontrolled HTN, cancer patients with radiation alone 6 months 22

23 Everolimus (Zortress) ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG 23

24 Evolocumab (Repatha) REPATHA PUSHTRONEX, REPATHA SURECLICK, REPATHA SYRINGE 24

25 Ezetimibe (Zetia) ezetimibe 25

26 Fentanyl Lozenge fentanyl citrate Opiod tolerant 26

27 Fentanyl Transdermal Patch fentanyl Refractory or intolerant to oral pain management 27

28 Fidaxomicin (Dificid) DIFICID 10 days 28

29 Filgrastim (Neupogen) ZARXIO not for afebrile neutropenia 6 months None 29

30 glecaprevir/pibrentasvir (Mavyret) MAVYRET. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 30

31 Golimumab (Simponi) SIMPONI, SIMPONI ARIA 31

32 guselkumab (Tremfya) TREMFYA. 32

33 Imiquimod (Aldara) imiquimod topical cream in packet 4 months 33

34 Infliximab (Remicade) INFLECTRA, RENFLEXIS None 34

35 Interferon Beta 1A (Rebif, Avonex) AVONEX (WITH ALBUMIN), AVONEX INTRAMUSCULAR PEN INJECTOR KIT, AVONEX INTRAMUSCULAR SYRINGE KIT, REBIF (WITH ALBUMIN), REBIF REBIDOSE, REBIF TITRATION PACK Neurologist 3 months 35

36 Ivacaftor (Kalydeco) KALYDECO 36

37 Ledipasvir/Sofosbuvir (Harvoni) HARVONI 12 weeks in patients without cirrhosis, 24 weeks in patients with cirrhosis 37

38 Lenalidomide (Revlimid) REVLIMID 3 months 38

39 Levomilnacipran (Fetzima) FETZIMA 39

40 Linezolid (Zyvox) linezolid, linezolid in dextrose 5% 28 days 40

41 Lomitapide Mesylate (Juxtapid) JUXTAPID 41

42 Lubiprostone (Amitiza) AMITIZA 42

43 Lumacaftor/Ivacaftor (Orkambi) ORKAMBI ORAL TABLET 43

44 Macitentan (Opsumit) OPSUMIT 44

45 Megestrol megestrol oral suspension 400 mg/10 ml (40 mg/ml) Assess for weight gain after initial coverage duration 6 months 45

46 Methylnaltrexone (Relistor) RELISTOR ORAL, RELISTOR SUBCUTANEOUS SOLUTION, RELISTOR SUBCUTANEOUS SYRINGE 46

47 Mipomersen Sodium (Kynamro) KYNAMRO 47

48 Modafanil (Provigil) modafinil None 48

49 Natalizumab (Tysabri) TYSABRI. 49

50 Nintedanib Esylate (Ofev) OFEV 50

51 Parathyroid Hormone (Natpara) NATPARA 51

52 Pimavanserin tartrate (Nuplazid) NUPLAZID ORAL CAPSULE, NUPLAZID ORAL TABLET 17 MG 52

53 Pirfenidone (Esbriet) ESBRIET 53

54 Plerixafor (Mozobil) MOZOBIL 4 days 54

55 Pomalidomide (Pomalyst) POMALYST 3 months 55

56 Quinine Sulfate quinine sulfate 1 week 56

57 Ribavirin Oral REBETOL ORAL SOLUTION, ribavirin oral capsule, ribavirin oral tablet 200 mg 3 months 57

58 Rifaximin (Xifaxan) XIFAXAN ORAL TABLET 200 MG 3 days 58

59 Riociguat (Adempas) ADEMPAS 59

60 Roflumilast (Daliresp) DALIRESP 60

61 Rotigotine (Neupro) NEUPRO 61

62 Sacubitril/Valsartan (Entresto) ENTRESTO. 62

63 sargramostim (Leukine) LEUKINE INJECTION RECON SOLN 2 months 63

64 Selegilene transdermal EMSAM 64

65 Selexipag (Uptravi) UPTRAVI 65

66 Sildenafil Citrate (Revatio) sildenafil (antihypertensive) oral 66

67 Sirolimus (Rapamune) RAPAMUNE ORAL SOLUTION, sirolimus 67

68 Sofosbuvir (Solvaldi) SOVALDI 12, 16, 24 or 48 weeks Consider genotype, cirrhosis status, previous failure of PEG-IFN/RBV/protease inhibitors/sofosbuvir, HCV in an allograft, decompensated cirrhosis, if awaiting transplant and concurrent treatment 68

69 Sofosbuvir and Velpatasvir (Epclusa) EPCLUSA. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 69

70 sofosbuvir/velpatasvir/voxilaprevir (Vosevi) VOSEVI. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 70

71 Somatropin GENOTROPIN, GENOTROPIN MINIQUICK, HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZEN SAIZENPREP, SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG, ZORBTIVE 71

72 Tacrolimus (Prograf) ASTAGRAF XL, ENVARSUS XR, tacrolimus oral 72

73 Tadalafil (Adcirca) ADCIRCA 73

74 Tasimelteon (Hetlioz) HETLIOZ 74

75 Tedizolid Phosphate (Sivextro) SIVEXTRO 6 days 75

76 Teriflunomide (Aubagio) AUBAGIO 1 year 76

77 Teriparatide (Forteo) FORTEO 2 years None 77

78 tetrahydrocannabinol dronabinol 78

79 Ticagrelor (Brilinta) BRILINTA 79

80 Tigecycline (Tygacil) tigecycline 14 days 80

81 Tofacitinib Citrate (Xeljanz) XELJANZ, XELJANZ XR 81

82 Treprostinil (Remodulin) REMODULIN 82

83 Vancomycin Oral Solution vancomycin oral capsule 2 weeks None 83

84 Varenicline (Chantix) CHANTIX, CHANTIX CONTINUING MONTH BOX, CHANTIX STARTING MONTH BOX 12 weeks and may extend up to 24 weeks if have stopped smoking after initial 12 weeks of therapy. None 84

85 Vilazodone (Viibryd) VIIBRYD ORAL TABLET, VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 85

86 Vortioxetine (Trintellix) TRINTELLIX 86

87 87