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 Dacomitinib (Vizimpro) VIZIMPRO. 5

6 Dalfampridine (Ampyra) dalfampridine 6

7 Daptomycin (Cubicin) daptomycin 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 Dextromethorphan/Quinidine (Nuedexta) NUEDEXTA 9

10 Diclofenac (Solaraze) diclofenac sodium topical gel 3 % 10

11 Diclofenac Epolamine (Flector) FLECTOR 2 weeks 11

12 Dimethyl Fumarate (Tecfidera) TECFIDERA 12

13 Dornase Alfa (Pulmozyme) PULMOZYME 13

14 Droxidopa (Northera) NORTHERA 14

15 Dulaglutide (Trulicity) TRULICITY 15

16 Duvelisib (Copiktra) COPIKTRA. 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 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 19

20 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 20

21 Everolimus (Zortress) ZORTRESS 21

22 Evolocumab (Repatha) REPATHA PUSHTRONEX, REPATHA SURECLICK, REPATHA SYRINGE 22

23 Ezetimibe (Zetia) ezetimibe 23

24 Fentanyl Lozenge fentanyl citrate Opiod tolerant 24

25 Fentanyl Transdermal Patch fentanyl Refractory or intolerant to oral pain management 25

26 Fidaxomicin (Dificid) DIFICID 10 days 26

27 Filgrastim (Neupogen) NIVESTYM, ZARXIO not for afebrile neutropenia 6 months None 27

28 glecaprevir/pibrentasvir (Mavyret) MAVYRET. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 28

29 Golimumab (Simponi) SIMPONI 29

30 guselkumab (Tremfya) TREMFYA. 30

31 Imiquimod (Aldara) imiquimod 4 months 31

32 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 32

33 Ivacaftor (Kalydeco) KALYDECO 33

34 Ledipasvir/Sofosbuvir (Harvoni) ledipasvir-sofosbuvir 12 weeks in patients without cirrhosis, 24 weeks in patients with cirrhosis 34

35 Lenalidomide (Revlimid) REVLIMID 3 months 35

36 Levomilnacipran (Fetzima) FETZIMA 36

37 Linezolid (Zyvox) linezolid, linezolid in dextrose 5% 28 days 37

38 Lomitapide Mesylate (Juxtapid) JUXTAPID 38

39 Lorlatinib (Lorbrena) LORBRENA. 39

40 Lubiprostone (Amitiza) AMITIZA 40

41 Lumacaftor/Ivacaftor (Orkambi) ORKAMBI 41

42 Macitentan (Opsumit) OPSUMIT 42

43 Megestrol megestrol oral suspension 400 mg/10 ml (40 mg/ml) Assess for weight gain after initial coverage duration 6 months 43

44 Methylnaltrexone (Relistor) RELISTOR ORAL, RELISTOR SUBCUTANEOUS SOLUTION, RELISTOR SUBCUTANEOUS SYRINGE 44

45 Mipomersen Sodium (Kynamro) KYNAMRO 45

46 Modafanil (Provigil) modafinil None 46

47 Nintedanib Esylate (Ofev) OFEV 47

48 Parathyroid Hormone (Natpara) NATPARA 48

49 Pimavanserin tartrate (Nuplazid) NUPLAZID 49

50 Pirfenidone (Esbriet) ESBRIET 50

51 Pomalidomide (Pomalyst) POMALYST 3 months 51

52 Quinine Sulfate quinine sulfate 1 week 52

53 Ribavirin Oral REBETOL ORAL SOLUTION, ribavirin oral capsule, ribavirin oral tablet 200 mg 3 months 53

54 Rifaximin (Xifaxan) XIFAXAN ORAL TABLET 200 MG 3 days 54

55 Riociguat (Adempas) ADEMPAS 55

56 Roflumilast (Daliresp) DALIRESP 56

57 Rotigotine (Neupro) NEUPRO 57

58 Sacubitril/Valsartan (Entresto) ENTRESTO. 58

59 sargramostim (Leukine) LEUKINE INJECTION RECON SOLN 2 months 59

60 Selegilene transdermal EMSAM 60

61 Selexipag (Uptravi) UPTRAVI 61

62 Sildenafil Citrate (Revatio) sildenafil (antihypertensive) oral 62

63 Sirolimus (Rapamune) RAPAMUNE ORAL SOLUTION, sirolimus 63

64 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 64

65 Sofosbuvir and Velpatasvir (Epclusa) EPCLUSA, sofosbuvir-velpatasvir. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 65

66 sofosbuvir/velpatasvir/voxilaprevir (Vosevi) VOSEVI. 12 weeks Criteria will be applied consistent with current AASLD/IDSA guidance 66

67 Somatropin GENOTROPIN, GENOTROPIN MINIQUICK, HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG, ZORBTIVE 67

68 Tacrolimus (Prograf) ASTAGRAF XL, ENVARSUS XR, tacrolimus oral 68

69 Tadalafil (Adcirca) ADCIRCA 69

70 Tasimelteon (Hetlioz) HETLIOZ 70

71 Tedizolid Phosphate (Sivextro) SIVEXTRO 6 days 71

72 Teriflunomide (Aubagio) AUBAGIO 1 year 72

73 Teriparatide (Forteo) FORTEO 2 years None 73

74 tetrahydrocannabinol dronabinol 74

75 Ticagrelor (Brilinta) BRILINTA 75

76 Tigecycline (Tygacil) tigecycline 14 days 76

77 Tofacitinib Citrate (Xeljanz) XELJANZ, XELJANZ XR 77

78 Vancomycin Oral Solution vancomycin oral capsule 2 weeks None 78

79 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 79

80 Vilazodone (Viibryd) VIIBRYD ORAL TABLET, VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 80

81 Vortioxetine (Trintellix) TRINTELLIX 81

82 82