UnitedHealthcare® Oxford Clinical Policy DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.161 T0 Effective Date: June 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE ......................................................................... 1 CONDITIONS OF COVERAGE..................................................................... 1 DESCRIPTION OF SERVICES ..................................................................... 2 DEFINITIONS ......................................................................................... 2 PAYMENT GUIDELINES............................................................................. 3 POLICY HISTORY/REVISION INFORMATION ............................................ 145 Related Policies Refer to Payment Guidelines below INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE This policy applies to Oxford plan membership. Notes: Not all Oxford groups have selected the same pharmacy benefits. Refer to the group's pharmacy plan number for specific exclusions, exceptions, and dispensing limitations. New Jersey (NJ) Small Members should refer to their certificate of coverage for precertification and quantity limit guidelines. Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 1 of 147 Effective 06/01/2017 DESCRIPTION OF SERVICES The Drug Coverage Guidelines table of medications contains medications that: o Have a quantity limit in place; and/or o Require precertification through Oxford's Pharmacy Benefit Manager (PBM); and/or o Require precertification through Oxford's Medical Management; and/or o Are standard exclusions (such as weight loss medications, fluorides, vitamins) Medications are listed alphabetically with an explanation of how precertification is obtained and under which benefit it is covered. While a medication by itself may not require precertification, Home Care for the administration of a medication does require precertification. Exception: The first seven days of therapy with low molecular weight heparin are an exception to the Home Care precertification requirement. Notes: Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. To request coverage for a greater quantity of a medication with a QLL, providers must call Oxford's Pharmacy Benefit Manager (PBM). For information regarding QD or QLL supply limits, refer to the following documents on UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Clinical Programs > Supply Limits: o QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) o QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment) Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM. For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM. For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly. Over-the-Counter (OTC) Medications: o NJ Plans: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are not excluded from coverage. Refer to specific drug policies where applicable. o Connecticut (CT) and New York (NY) Plans: A prescription drug product that is therapeutically equivalent to an over-the-counter (OTC) drug may be covered if it is determined to be medically necessary. In order for a prescription drug to be deemed "medically necessary" when there is an equivalent OTC drug available, the physician must show that there is something about the prescription drug that is superior to the OTC drug, and likely to be more beneficial to the Member than the OTC drug. Documentation supporting medical necessity must be submitted by the provider. New FDA-approved drug products may require precertification immediately upon launch of the medication. For information on coverage of recent FDA-approved drug products for which drug-specific criteria are unavailable, please refer to Interim New Product Coverage Criteria. New Jersey Formulary Regulations: Members who are enrolled in a New Jersey group Product with a 3-Tier Prescription Drug Benefit and for whom the NJ Formulary Regulations apply should refer to Prior Authorization/Notification Non-Formulary (i.e., Tier 3 or higher) Copay Adjustment – New Jersey. DEFINITIONS For all of the definitions below, copayment/cost share will vary based on the Member’s plan design. Refer to the Member's specific certificate of coverage, contract and/or prescription drug rider as applicable. Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of certain prescription medications (new or refill) by mail. Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription medications (new or refill). Note: For Members enrolled in NY LOBs new and renewing on or after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be available at the same co-payment or other reimbursement level that would apply to the mail-order or non-retail specialty pharmacies (should any of these pharmacies be available in the service area). Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 2 of 147 Effective 06/01/2017 Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty medications at an in-network benefit level for members enrolled on NY and NJ LOBs. PAYMENT GUIDELINES The following list of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. Medication/Drug Dosage Form IM injection Abilify (aripiprazole) Tablet, oral suspension CPT/HCPCS Code(s) J0400 and J1942 Precertification Routing N/A Coverage Criteria/Guidelines N/A J8499 PBM Absorica (isotretinoin) Capsule J8499 PBM Abstral (fentanyl) Acanya (clindamycin phosphate 1.2% and benzoyl peroxide 2.5%) Aciphex (rabeprazole) Tablet or Sublingual Tablet J8499 PBM Topical J3490 PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Benefit Type Notes Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Absorica (isotretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Abstral (fentanyl) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 3 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Aciphex Sprinkle (rabeprazole) Capsule Acova (argatroban) IV Injection J8499 PBM J0883 and J0884 N/A N/A SQ Injection J3490 PBM Actemra (tocilizumab) Injection J3262 Oxford’s Medical Management Acticlate (doxycycline hyclate) Tablet Actimmune (interferon gamma-1b) SQ Injection J8499 PBM J9216 PBM Actiq (fentanyl citrate) Lozenge Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Actemra (tocilizumab) Injection for Intravenous Infusion Step Therapy Guidelines: Actemra (tocilizumab) Injection for Intravenous Infusion Precertification Guidelines: o Actemra (tocilizumab) Injection for Intravenous Infusion o Specialty Medication Administration – Site of Care Review Guidelines Benefit Type Notes Pharmacy N/A Medical N/A Pharmacy N/A Medical Hospital Outpatient Facility: Administration of Actemra in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Actimmune (interferon gamma1b) Pharmacy N/A Prior Authorization/ Notification Guidelines: Actiq (fentanyl citrate) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 4 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Actos (brand only) (pioglitazone) Tablet Acuvail (ketorlac/ tromethamine) Ophthalmic Solution J3490 PBM Aczone 7.5% (dapsone) Topical Gel J3490 N/A Adcirca (tadalafill) Tablet J3490 PBM J8499 PBM Adderall (amphetamine/ dextroamphetamin) (brand only) Tablet S0160 PBM Adderall XR amphetamine/ dextroamphetamin [extended release]) Tablet S0160 PBM Addyi (flibanserin) Tablet J8499 PBM Adempas (riociguat) Tablet J8499 PBM Adlyxin (lixisenatide) Injection J3490 Capsule Adrenaclick (epinephrine) Pen Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Adcirca (tadalafill) Pharmacy N/A Prior Authorization/ Notification Guidelines: Adderall and Adderall XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Adderall and Adderall XR Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Addyi Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Adempas Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM PBM PBM Benefit Type J0171 Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Adoxa (doxycycline monohydrate) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 5 of 147 Effective 06/01/2017 Medication/Drug Adynovate (antihemophillic factor) Dosage Form CPT/HCPCS Code(s) Precertification Routing Injection J3490 PBM Adzenys XR (amphetamine extended-release Orally disintergrating tablet J8499 PBM Afinitor (everolimus) Oral J7527 PBM* Afrezza (Insulin, human) Inhalation Powder J3490 PBM Afstyla (Antihemophilic Factor [Recombinant] Single Chain) Injection J7192 PBM Akynzeo (netupitant/ palonosetron) Capsule J8499 N/A Albenza (albendazole) Tablet J8499 PBM Aldurazyme® (laronidase) Intravenous J1931 N/A Alecensa (alectinib) Capsule J8999 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Adzenys XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Prior Authorization/ Notification Guidelines: Afinitor Prior Authorization/Medical Necessity Guidelines: Afrezza Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A N/A Authorization/Medical Necessity Guidelines: Albenza N/A Prior Authorization/ Notification Guideline: Alencensa ©1996-2017, Oxford Health Plans, LLC Pharmacy** Page 6 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Alesse (ethinyl estradiol and levonorgestrel) Pills S4993 N/A Allegra D (fexofenadine & pseudoephedrine), Allegra suspension/ Allegra ODT Tablet J8499 N/A Allzital (allzital butalbital/ acetaminophen) Alogliptin (Nesina Authorized Generic) Alogliptin/ Metformin (Kazano Authorized Generic) Coverage Criteria/Guidelines N/A Tablet J8499 PBM Tablet J8499 PBM Tablet Alogliptin/ Pioglitazone (Oseni Authorized Generic) Tablet Alpha Baclofen (baclofen) Injection and Intrathecal J8499 PBM J8499 PBM J0475 and J0476 N/A Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Pharmacy* Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Medical N/A Pharmacy N/A N/A Alsuma (sumatriptan) Benefit Guidelines: Contraceptives Benefit Type Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 7 of 147 Effective 06/01/2017 Medication/Drug Altoprev (lovastatin) Dosage Form CPT/HCPCS Code(s) Precertification Routing tablet J3490 PBM Ambien (zolpidem tartrate) Ambien CR (zolpidem tartrate extendedrelease[ER]) Tablet J8499 PBM Tablet J8499 PBM Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Amerge (naratriptan) Tablet J8499 PBM* Amevive (alefacept) Injection, SQ Injection J0215 N/A N/A Medical N/A Aminolevulinic acid HCL Topical J7308 N/A N/A Medical N/A Amitiza (lubiprostone) Capsule J8499 PBM Pharmacy N/A Amlodipine/ Atorvastatin (generic) Tablets J8499 N/A Pharmacy N/A Amnesteem (isotretinoin) Capsule J8499 PBM Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Supply Limit Guidelines: Triptans Supply Limits *Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. **Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Prior Authorization/Medical Necessity Guidelines: Amitiza (lubiprostone) N/A Prior Authorization/ Notification Guidelines: Amnesteem ©1996-2017, Oxford Health Plans, LLC Pharmacy** Page 8 of 147 Effective 06/01/2017 Medication/Drug Dosage Form Amphetamine/ dextroamphetamine Tablet extended-release (generic Adderall XR) Ampyra (dalfampridine) Amrix / cyclobenzaprine extended release Tablet Capsule CPT/HCPCS Code(s) Precertification Routing J8499 J8499 J8499 PBM PBM** Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Adderall and Adderall XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Pharmacy Notes N/A **Precertification Note: Precertification through the PBM is required for Members age 19 and older. *Benefit Note: NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Prior Authorization/ Notification Guidelines: Ampyra (dalfampridine) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM Amturnide (aliskiren, Tablet amlodipine, hydrochlorothiazide) J8499 PBM Anabolin (nandrolone deconoate) Injection J2320 N/A N/A Medical N/A Anadrol-50 (oxymetholone) Tablet J8499 N/A N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Androderm Pharmacy N/A Anafranil (clomipramine) (brand) Pharmacy* Capsule J8499 PBM Analpram Advanced Kit (hydrocortisone Cream acetate/pramoxine) J3490 PBM Androderm (testosterone) J3490 PBM Gel Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 9 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Androgel (testosterone) Gel J3490 PBM Android, Oreton, Methyl, Virilon and Methitest (methyltestosterone) Tablet J8499 N/A N/A Antagon (ganirelix) Antara (fenofibrate) 30mg and 90mg strengths only Antara 43mg, 130mg (fenofibrate) Anusol HC Suppository (brand) (hydrocortisone) Anzemet (dolasetron) Injection Capsule S0132* and J3490 J8499 Precertification through Optum may be required* J3490 Benefit Type Notes Pharmacy N/A Pharmacy N/A Precertification Guidelines: Infertility Diagnosis and Treatment Pharmacy/ Medical** *Precertification Notes: HCPCS code S0132 (ganirelix) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Notes: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM Capsule Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Androgel Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Suppository J8499 PBM Injection J1260 N/A N/A Medical N/A Tablet Q0180 N/A N/A Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 10 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Aplenzin (bupropion) Tablet J8499 PBM Apligraf Patch Q4101 N/A Apop 10% gel (sulfacetamide) Topical Gel J3490 Apriso (mesalamine) Capsule J8499 N/A Medical N/A N/A N/A Pharmacy N/A N/A N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Aptensio XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Aptiom (eslicarbazepine acetate) Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Capsule J8499 PBM Aptiom (eslicarbazepine acetate) Tablet J8499 PBM Aranesp (darbepoetin) Arcalyst (rilonacept) Aricept 23mg (donepezil hydrochloride) J3490 PBM Injection, SQ Injection J0882ESRD OR J0881-NonESRD Oxford’s Medical Management Department* Injection, SQ Injection J2793 PBM Tablet J8499 PBM Arimidex (brand only) (anastrozole) Tablet J8499 PBM Arixtra (fondaparinux) Injection, SQ Injection J1652 N/A* Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes N/A Aptensio XR Topical Benefit Type Pharmacy Aqua Glycolic HC (hydrocortisone) Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Select Brand Medications Precertification Guidelines: Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Methoxy Polyethylene Glycol-Epoetin Beta Medical *Precertification is required if provided in a hospital or MD's office. Prior Authorization/ Notification Guidelines: Rilonacept (Arcalyst) Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy *No precertification is required if dispensed by a retail pharmacy or Mail Order through PBM. N/A ©1996-2017, Oxford Health Plans, LLC Page 11 of 147 Effective 06/01/2017 Medication/Drug Arnuity Ellipta (fluticasone furoate) Dosage Form Inhalation Powder CPT/HCPCS Code(s) Precertification Routing J3490 N/A Coverage Criteria/Guidelines N/A Arymo ER (morphine sulfate) Tablet J8499 PBM Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Asacol HD (mesalamine) Tablet J8499 PBM AsmalPred and AsmalPred Plus (Prednisolone) Tablet J8499 N/A N/A Pharmacy N/A Asmanex HFA (mometasone) Inhaler J3490 N/A N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cardiovascular Disease Prevention Zero Cost Share* Pharmacy *Applies to New York Lines of Business only. Astagraf XL (tacrolimus) Astelin (brand) (azelastine) Capsule J8499 PBM Tablet J3490 PBM Astepro (azelastine) Atelvia (risedronate sodium) Ativan (brand only) (lorazepam) Atorvastatin (generic Lipitor) 10mg, 20mg Nasal Spray J3490 PBM Tablet J8499 PBM Tablet J8499 PBM Tablets Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM* ©1996-2017, Oxford Health Plans, LLC Page 12 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Atralin (tretinoin) Varies S0117 PBM** Aubagio (teriflunomide) Tablet J8499 PBM Augmentin (amoxicillin clavulanate) (brand) Augmentin ED-600 (amoxicillin clavulanate) (brand) Tablet J8499 J8499 Pharmacy* Notes **Precertification Notes: Precertification for NJ Small LOBs is based on the Member's benefit. *Benefit Note: Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Prior Authorization/ Notification Guidelines: Aubagio Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM Tablet Prior Authorization/ Notification Guidelines: Atralin (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type PBM Augmentin XR / AmoxicillinClavulanate ER (amoxicillin and clavulanate potassium) Tablet J8499 PBM Auralgan 5.5%/1.4% (antipyrine, benzocaine) Drops, Solution J3490 N/A N/A Pharmacy N/A Auryxia (ferric citrate) Tablet J8499 N/A N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Austedo (deutetrabenazine) Auvi-Q (epinephrine) Tablet J8499 PBM Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM ©1996-2017, Oxford Health Plans, LLC Page 13 of 147 Effective 06/01/2017 Medication/Drug Avar Foam (9.5%5%), Avar, Avar LS (sodium sulfacetamide/ sulfur) Avastin (bevacizumab) Avelox tablet (Brand Only) (moxifloxacin hcl) Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Topical J3490 PBM IV Infusion, Injection J9035 N/A* tablet J8499 Pharmacy Medical Management Guidelines: Maximum Dosage Policy Medical Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Avinza Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Avita (tretinoin) Pharmacy N/A Prior Authorization/ Notification Guidelines: Avodart (dutasteride) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Avonex Pharmacy N/A Capsules J8499 PBM Avita (tretinoin) Varies S0117 PBM Avodart (dutasteride) (brand) Capsule Avonex (Interferon Beta 1a) IM Injection or Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM J1826, Q3025 and Q3026 PBM Notes Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Avinza (morphine sulfate extended release) (brand only) Benefit Type ©1996-2017, Oxford Health Plans, LLC N/A *Non-Oncology Indications: No precertification required. Page 14 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Axert (almotriptan) (brand) Tablet J8499 PBM** Axiron (testosterone) Azilect (rasagiline) Gel Tablet J3490 J8499 PBM PBM Azor (amlodipine besylate and olmesartan medoxomil) Tablet J8499 PBM Banzel (Rufinamide) Tablets J8499 PBM Beconase AQ (beclomethasone dipropionate, monohydrate) Nasal Spray J3490 PBM Belbuca (buprenorphine) Buccal film J3490 PBM Belsomra (suvorexant) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Type Notes **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain triptan drugs are included in the select designated pharmacy program. Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy* Prior Authorization/Medical Necessity Guidelines: Axiron Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Step Therapy Guidelines: Azilect* Pharmacy *Step Therapy coverage criteria is for groups on the Essential PDL only. More information about if this program applies can be found on myuhc.com or by calling customer service. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Banzel (Rufinamide) Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Belbuca Pharmacy N/A Step Therapy Guidelines: Belsomra Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 15 of 147 Effective 06/01/2017 Medication/Drug Benlysta (belimumab) Benzaclin Jar (brand only) (benzoyl peroxide and clindamycin) Benzaclin Pump (benzoyl peroxide Dosage Form Injection CPT/HCPCS Code(s) Precertification Routing J0490 N/A Coverage Criteria/Guidelines N/A J3490 N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Berinert Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Betaseron Pharmacy N/A Prior Authorization/ Notification Guidelines: Bethkis Pharmacy N/A PBM Topical J3490 PBM and clindamycin) Benzaclin Kit (1%5%) (Clindamycin Phosphate-Benzoyl Peroxide) Gel Benzefoam BenzeFoam Ultra Aerosol/ Foam Bepreve (bepotastine) Ophthalmic Drops J3490 PBM Berinert (C1 esterase inhibitor human) Injection J0597 PBM J3490 PBM Betamethasone valerate foam (generic Luxiq) Topical J3490 PBM J3490 PBM Betapace (sotalol) (brand) Tablet Betaseron (Interferon Beta 1b) Injection Bethkis (tobramycin) Inhalation Solution Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM J1830 or J3490 PBM J3490 PBM Notes Medical Topical Benefit Type ©1996-2017, Oxford Health Plans, LLC Page 16 of 147 Effective 06/01/2017 Medication/Drug Bevespi Aerosphere (glycopyrrolate/ formoterol fumarate) Dosage Form Inhalation aerosol CPT/HCPCS Code(s) Precertification Routing J3490 N/A Capsule J8499 PBM Bexxar (tositumomab) Injection J3490 N/A bimatoprost 0.03% (generic Lumigan) N/A Bexarotene caps (generic Targretin) Beyaz (drospirenone/ ethinyl estradiol/ levomefolate) Coverage Criteria/Guidelines Tablet J8499 PBM Eye drops J3490 PBM Binosto (alendronate) Tablets J3490 Boniva (ibandronate sodium) Injection J1740 Boniva Tablets (ibandronate sodium) Tablet PBM N/A Tablet Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Pharmacy N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A N/A J8499 Pharmacy J8999 PBM Botox, Botulinum Toxin Type (onabotulinumtoxin A) N/A Medical Bosulif (bosutinib) J0585 Notes Pharmacy N/A Benefit Type Oxford’s Medical Management Department Prior Authorization/ Notification Guidelines: Bosutinib (bosulif) Step Therapy Guidelines: Bosutinib (bosulif) Precertification Guidelines: Botulinum Toxins A and B ©1996-2017, Oxford Health Plans, LLC Pharmacy N/A Medical N/A Page 17 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Bravelle (urofollitropin) IM or SQ Injection J3355 Precertification through Optum* Brilinta (Ticagrelor) Tablets J8499 N/A Brintellix (vortioxetine) Tablet J8499 PBM Brisdelle (paroxetine) Capsule J8499 PBM Briviact (brivaracetam) Tablet J8499 PBM Bromday (bromfenac) Ophthalmic Drops J3490 N/A Bromsite (bromfenac) Topical ophthalmic solution Budesonide nasal spray (generic Rhinocort Aqua) Coverage Criteria/Guidelines N/A J3490 Pharmacy N/A Step Therapy Guidelines: Brintellix Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Briviact Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products Pharmacy N/A N/A PBM Nasal Spray See Notes* Notes *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit.* *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. J3490 Precertification Guidelines: Follicle Stimulating Hormone (FSH) Gonadotropins Benefit Type PBM Bunavail Film (buprenorphine and naloxone) Buccal Film J3490 PBM Buprenorphine HCl Sublingual Tablet J3490 N/A N/A Pharmacy N/A Buprenorphine (generic Subutex) Tablet J3490 N/A N/A Pharmacy N/A Pharmacy N/A Buprenorphine / naloxone (generic Suboxone) Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products ©1996-2017, Oxford Health Plans, LLC Page 18 of 147 Effective 06/01/2017 Medication/Drug Bupropion (generic Zyban) Butalbital / acetaminophen / caffeine / codeine 50mg / 300mg / 40mg / 30mg (generic Fioricet with Codeine) Dosage Form Tablet Capsule CPT/HCPCS Code(s) Precertification Routing J8499 PBM J8499 Coverage Criteria/Guidelines Patch J3490 Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform Pharmacy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Butrans Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy Coverage Criteria does not apply to CT of business. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cabometyx Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM PBM Tablet J8499 PBM Cabometyx (cabozantinib) Capsule J8999 PBM Caduet and generic Caduet (amlodipine and atorvastatin) Byvalson (nebivolol and valsartan) Tablet J8499 Notes Benefits for Smoking Cessation for Health Care Reform apply to all plans subject to health care reform. Butrans (buprenorphine) Benefit Type PBM Calcijex (Calcitriol) Injection J0636 N/A N/A Medical* *Injectable prescription vitamins administered under the direction of a physician as medically necessary are reimbursed under the Medical Benefit. Calderol (calcifediol) Capsule J8499 N/A N/A Pharmacy N/A Cambia (diclofenac potassium) Powder. Tablet, Capsule Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 19 of 147 Effective 06/01/2017 Medication/Drug Capecitabine (generic Xeloda) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8999 PBM Caprelsa (vandetanib) Oral J8999 PBM* Cardizem (diltiazem) (brand) Tablet J8499 PBM Cardizem CD (diltiazem) (brand) Tablet J8499 PBM Cardizem LA (diltiazem) (brand) Tablet J8499 PBM Carnitor (levocarnitine/ L-Carnitine) Caverject (alprostadil) Tablet or Solution J8499 N/A Injection J1955 N/A Vial J0270 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Caprelsa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Benefit Type Notes Pharmacy N/A Pharmacy* * Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy* Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the Member does not have vitamin/ supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Medical Management Guidelines: Formula & Specialized Food Medical* *Benefit is State Specific. Medical Benefit/Pharmacy Benefit. Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Oxford Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 20 of 147 Effective 06/01/2017 Medication/Drug Cayston (Aztreonam for Inhalation Solution) Dosage Form Inhalation Solution CPT/HCPCS Code(s) Precertification Routing J3490 PBM* Celebrex (brand only) (celecoxib) Capsule J3490 PBM Celexa (citalopram) (brand only) Tablet J8499 PBM Cenestin (conjugated estrogens) (brand only) tablet J8499 J3490 PBM Cerdelga (eliglustat) Capsule J8499 PBM Ceredase® (algucerase) IV Infusion, Injection J0205 N/A Cerezyme® (imiglucerase) IV Infusion, Injection J1786 Oxford’s Medical Management Cesamet (nabilone) Capsule J8650 N/A Oral solution Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 N/A Notes Prior Authorization/ Notification Guidelines: Cayston Pharmacy* *NJ Small Members should refer to their certificate of coverage for precertification guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Select Brand Medications Oxford Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cerdelga Pharmacy N/A Medical N/A Medical N/A Pharmacy N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Ointment Benefit Type PBM Centany AT Kit (mupirocin) Cetirizine Solution (generic Zyrtec) Coverage Criteria/Guidelines N/A Precertification Guidelines: Enzyme Replacement Therapy (ERT) for Gaucher Disease N/A N/A ©1996-2017, Oxford Health Plans, LLC Page 21 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Cetrotide (cetrorelix acetate) Injection J3490 Precertification through Optum may be required Cetylev (acetylcysteine) Tablet J8499 N/A Chantix (varenicline tartrate) Tablet Chelation Therapy J3490 PBM IV Infusion J3490 M0300 and S9355 Oxford’s Medical Management* Chemotherapy (Injectable) Drugs Injection J0640J0641 J9000J9999 Q2017 Q2043 Q2049 and Q2050 eviCore* Cholbam (cholic acid) Capsule J8499 PBM Choline Fenofibrate (generic Trilipix) Chorionic Gonadatropin Tablet Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J0725* and J3490 Coverage Criteria/Guidelines N/A Pharmacy/ Medical* Notes Benefit Note: *Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform Pharmacy* Benefits for Smoking Cessation for Health Care Reform apply to all plans subject to health care reform. Precertification Guidelines: Chelation Therapy Medical N/A eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Medical *Precertification is required through eviCore. Prior Authorization/ Notification Guidelines: Cholbam Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J0725 (chorionic gonadatropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is PBM Precertification through Optum may be required* Precertification Guidelines: Infertility Diagnosis and Treatment Benefit Type Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Page 22 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing J3490 PBM Coverage Criteria/Guidelines Cialis (tadalafil) Ciclodan Combination Package (ciclopirox) Tablet J3490 N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cimzia (certolizumab pegol) Pharmacy N/A Precertification Guidelines: Respiratory Interleukins (IL) Policy Medical N/A Prior Authorization/Medical Necessity Guidelines: Cinryze Pharmacy N/A Topical J3490 PBM Cimzia (certolizumab pegol) SQ Injection J0717 PBM Cinqair (reslizumab) Intravenous infusion J3490, J3590, and J2786 Oxford’s Medical Management Cinryze (C1 esterase inhibitor (human)) Injection J0598 PBM Tablet J8499 Injection J0744 Cipro suspension (Brand Only) (ciprofloxacin) Oral Suspension Cipro XR (ciprofloxacin extended-release) Tablet Cipro (ciprofloxacin) Pharmacy PBM Ciclodan Kit (ciclopirox) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Oxford Topical Benefit Type Pharmacy N/A N/A J8499 N/A N/A Pharmacy N/A J8499 N/A N/A Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Medical N/A Page 23 of 147 Effective 06/01/2017 Medication/Drug Ciprodex (ciprofloxacin HCL/dexamethaso ne) Dosage Form Tablet CPT/HCPCS Code(s) Precertification Routing J8499 PBM Claforan (cefotaxime sodium) IV Infusion J0698 Oxford’s Medical Management* Claravis (isotretinoin) Capsule J8499 PBM Clarifoam EF (sulfacetamide / sulfur) (brand) Topical Foam Clarinex (desloratadine) J3490 Tablet J8499 Precertification Guidelines: Lyme Disease Medical Prior Authorization/ Notification Guidelines: Claravis Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM Clarinex Reditab (desloratadine orally disintegrating tablet) Tablet J8499 N/A N/A Topical J3490 PBM Topical Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Pharmacy Notes *Step Therapy coverage criteria is for groups on the Essential PDL only. More information about if this program applies can be found on myuhc.com or by calling customer service. PBM J8499 Step Therapy Guidelines: Ciprodex Benefit Type *Precertification is only required only when used in the treatment of Lyme disease. Exception: Precert is not required for Connecticut Members. Tablet Clindagel (clindamycin) PBM Clarinex D (desloratadine and pseudoephedrine) Clindacin Pack (clindamycin phosphate) Coverage Criteria/Guidelines ©1996-2017, Oxford Health Plans, LLC Page 24 of 147 Effective 06/01/2017 Medication/Drug Clindamycin 1%/benzoyl peroxide 5% (generic BenzaClin) gel Clindamycin1.2%/ benzoyl peroxide 5% gel (Generic Duac) Clobeta (Clobetasol) Clobetasol shampoo (generic Clobex shampoo) Clobex Lotion (clobetasol propionate) Clobex Shampoo (clobetasol propionate) Clodan 0.05% (clobetasol proprionate) Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Gel J3490 PBM Topical J3490 N/A Ointment J3490 and J8499 PBM J3490 PBM Lotion J3490 PBM Shampoo J3490 PBM Topical J3490 PBM Clodan 0.05% kit (clobetasol proprionate) Topical J3490 PBM Cloderm 0.1% cream (clocortolone) Cream J3490 PBM Cloderm cream (Brand Only (clocortolone) Cream J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Step Therapy Guidelines: Cloderm Pharmacy N/A Pharmacy N/A N/A Gel Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type N/A ©1996-2017, Oxford Health Plans, LLC Page 25 of 147 Effective 06/01/2017 Medication/Drug Cocet Plus (acetaminophen and codeine phosphate) Colazal (balsalazide) (brand) Colchicine Capsule (manufacturer: West-Ward) Dosage Form Tablet CPT/HCPCS Code(s) J3490 and J8499 Precertification Routing PBM Capsule J8499 PBM Capsule J8499 PBM Colchicine Tablet (manufacturer: Prasco Tablet J8499 PBM Colcrys (colchicine) Cometriq (cabozantinib) Tablet Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J8999 PBM PBM* Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Colchicine Tablet Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Colcrys Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* * Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Prior Authorization/ Notification Guidelines: Cometriq ©1996-2017, Oxford Health Plans, LLC Page 26 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Comfort Pac w/ Tizanidine (tizanidine) Capsule J8499 PBM Compounds and Bulk Powders: various drugs Various J7999 PBM Concerta (methylphenidate) Tablet J8499 PBM Capsule J8499 PBM Copaxone (glatiramer acetate) Injection, SQ Injection J1595 PBM Copaxone (glatiramer acetate) 40mg Injection J3490 PBM Copegus (ribarivin) Tablet J3490 and J3590 N/A Cordran 0.05 % cream (clurandrenolide) Cream J3490 PBM Cordran 0.05% lotion (flurandrenolide) Lotion J3490 PBM Cordran Ointment (flurandrenolide) Topical Ointment J3490 PBM Coreg CR (carvedilol phosphate) Capsule Corgard (nadolol) Corlanor (ivabradine) PBM Tablet J3490 N/A Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes N/A Prior Authorization/ Notification Guidelines: Compounds and Bulk Powders Pharmacy *NJ Small Members should refer to their certificate of coverage for precertification guidelines. Prior Authorization/ Notification Guidelines: Concerta Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Copaxone Pharmacy N/A Prior Authorization/ Notification Guidelines: Copaxone Pharmacy N/A Pharmacy N/A J3490 and J8499 Benefit Type Pharmacy Conzip (tramadol) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Step Therapy Guidelines: Cordran Pharmacy N/A Step Therapy Guidelines: Cordran Pharmacy N/A Step Therapy Guidelines: Cordran Ointment Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Prior Authorization/ Notification Guidelines: Corlanor ©1996-2017, Oxford Health Plans, LLC Page 27 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Cosentyx (secukinumab) Injection Cosopt PF (dorzolamide hcl / timolol maleate Ophthalmic solution J3490 PBM Cotellic (cobimetinib) Tablet J8999 PBM Cresemba (isavuconazonium sulfate) capsule J8499 N/A Crestor (rosuvastatin calcium) Crinone (progesterone gel) Crinone 8% (progesterone) J3490 PBM Gel Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J3490 J3490 PBM N/A Precertification through Optum may be required Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cotellic Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy* *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy/ Medical* *Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. N/A Tablet Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Cosentyx Step Therapy Guidelines: Cosentyx Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Infertility Diagnosis and Treatment Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Page 28 of 147 Effective 06/01/2017 Medication/Drug Crofab (crotalidae polyvalent immune fab (ovine) Cultivate (fluticasone propionate 0.05%) Cuprimine (penicillamine) Dosage Form CPT/HCPCS Code(s) Precertification Routing Injection J0840 N/A Lotion J3490 PBM Capsule J8499 Coverage Criteria/Guidelines N/A Benefit Type Notes Medical N/A Step Therapy Guidelines: Cultivate Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Precertification Guidelines: o Immune Globulin (IVIG & SCIG) o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Medical N/A PBM Cuvitru [immune globulin subcutaneous (human)] Injection 90284 Oxford’s Medical Management Cyclophosphamide (Cytoxan) Oral J8530 N/A N/A Pharmacy N/A J8999 N/A N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Cystaran (cysteamine) Pharmacy N/A Medical N/A Prior Authorization/Medical Necessity Guidelines: o Daklinza - CT/NJ o Daklinza - NY Pharmacy N/A Prior Authorization/ Notification Guidelines: Daliresp Pharmacy* *NJ Small Members should refer to their certificate of coverage for precertification guidelines. Cyclophosph Capsule capsules (cyclophosphamide) Cymbalta (duloxetine) (brand only) Capsule J8499 PBM Cystaran (cysteamine) Ophthalmic Solution J3490 PBM Cytogam (cytomegalovirus immune globulin intravenous (human) Injection 90291 or J0850 N/A N/A Daklinza (daclatasvir) Tablet J3490 PBM Daliresp (Roflumilast) Tablet J3490 PBM* Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 29 of 147 Effective 06/01/2017 Medication/Drug Daraprim (pyrimethamine) Darbepoetin Alfa (Aranesp) Daxbia (cephalexin) Dosage Form Tablet Injgection, SQ Injection CPT/HCPCS Code(s) J3490 J0882ESRD OR J0881-NonESRD Precertification Routing PBM Oxford’s Medical Management* Capsule J8499 PBM Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Daraprim Benefit Type Notes Pharmacy N/A Benefit Guidelines: Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Methoxy Polyethylene Glycol-Epoetin Beta Pharmacy *No precertification is required if dispensed by a retail pharmacy through the PBM. *Precertification is required if provided in a hospital or MD's office. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Daytrana Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Daytrana (methylphenidate) Patch J3490 PBM Deca-Durabolin (nandrolone) Injection J2320 N/A N/A Medical N/A Delatestryl (testosterone enanthate) Injection J3490 N/A N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Depakote Pharmacy N/A Delos lotion/cleanser (benzoyl peroxide) Delzicol (mesalamine delayed release capsules) Topical J3490 PBM Capsule J8499 PBM Denavir (penciclovir) Cream J3490 PBM Depakote (divalproex sodium) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 30 of 147 Effective 06/01/2017 Medication/Drug Depakote ER (divalproex sodium extended release) Dosage Form Tablet CPT/HCPCS Code(s) J8499 Precertification Routing PBM Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Depakote ER Benefit Type Notes Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Depo Provera 150mg, DeposubQ provera 104 (medroxyprogesterone) Injection J3490 N/A Depo Provera 400mg (medroxyprogesterone) Injection J3490* N/A N/A Medical Only administered in MD's office. Depo Testosterone (testosterone cypionate) Injection J3490 N/A N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Step Therapy Guidelines: Desonate Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Dermasorb AF 30.5% kit (hydrocortisone) Topical J3490 PBM Dermasorb XM 39% kit (hydrocortisone) Topical J3490 PBM Descovy (emtricitabine / tenofovir alafenamide) Tablet J8499 N/A Tablet J8499 PBM Desonate 0.05% gel (desonide) Gel J3490 PBM Topical Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Benefit Guidelines: Contraceptives N/A Desloratadine (generic Clarinex) Desonil cream/ointment (Kit) (desonide) ©1996-2017, Oxford Health Plans, LLC Page 31 of 147 Effective 06/01/2017 Medication/Drug Desoxyn (methamphetamine) Desvenlafaxine (desvenlafaxine) Desvenlafaxine ER (desvenlafaxine) Dosage Form Tablet CPT/HCPCS Code(s) J3490 Precertification Routing N/A J8499 J8499 Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Dexedrine Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Focalin Pharmacy N/A Prior Authorization/ Notification Guidelines: Dextrostat Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM PBM Detrol (tolterodine) Detrol LA (tolterodine tartrate) Tablet J8499 PBM Capsule J3490 and J8499 PBM Dexedrine (dextroamphetamine) Tablet or Capsule S0160 PBM Dexilant (brand) (dexlansoprazole) Capsule J8499 N/A N/A Dexmethylphenidat e extended-release capsule (generic Focalin XR) Capsule Dextrostat (dextroamphetamine) Tablet D.H.E. 45 (dihydroergotamine) (brand) J8499 PBM Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy S0160 J3490 PBM PBM Notes N/A Tablet Benefit Type Pharmacy Tablet Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Desoxyn ©1996-2017, Oxford Health Plans, LLC Page 32 of 147 Effective 06/01/2017 Medication/Drug Diabetic Supplies Dosage Form Varies CPT/HCPCS Code(s) A4206, A4210, A4233A4236, A4244A4245, A4250, A4253, A4256, A4258A4259, A9275, E0607, E2100E2101, E0784, K0601K0605, A4230A4232, A6257, J1610, J1815, J1817 and J3490 Precertification Routing PBM Diclegis (doxylamine succinate and pyridoxine hydrochloride) J8499 PBM diclofenac 1% topical gel (generic Voltaren) Topical Gel J3490 PBM Dicloxacillin Sodium (Dycil, Dynapen) Capsule J8499 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes N/A N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Diclegis Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A J8499 Benefit Type Precertification Guidelines: Diabetes Supply Coverage for Commercial Plans (Including New Jersey Small Group Plans) N/A Dibenzyline Capsule (phenoxylbenzamine) (brand) Tablet Coverage Criteria/Guidelines N/A ©1996-2017, Oxford Health Plans, LLC Page 33 of 147 Effective 06/01/2017 Medication/Drug Differin (adapalene) Dosage Form Varies CPT/HCPCS Code(s) Precertification Routing J3490 and J8499 PBM** Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Differin (adapalene) Pharmacy* Prior Authorization/ Notification Guidelines: Differin (adapalene) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A N/A N/A Pharmacy N/A Medical N/A Topical Gel J3490 PBM Diflucan (fluconazole) Tablet J8499 N/A N/A Tablet J8499 PBM Diovan HCT (valsartan) (brand only) Tablet Disalcid (salsalate) Tablet and Capsule J8499 PBM Donepezil 5 or 10mg (generic Aricept) Oral Disintergrat -ing Tablet J8499 N/A J8499 PBM N/A Donepezil 23mg (generic Aricept 23mg) Tablet J8499 PBM Doribax (doripenem) IV Infusion J1267 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes **Precertification Note: Precertification is not required for Members under 30 years of age. *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Differin 0.3% Gel Diovan (valsartan) (brand only) Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A ©1996-2017, Oxford Health Plans, LLC Page 34 of 147 Effective 06/01/2017 Medication/Drug Dosage Form Tablet Doxorubicin Hydrochloride Liposomal Injection Doxycycline 150mg capsule (generic Monodox) Precertification Routing Doryx (doxycycline hyclate) delayed release tablet Doxycycline 75mg capsule (generic Monodox) CPT/HCPCS Code(s) J8499 PBM Q2049 and Q2050 N/A J8499 PBM Capsule J8499 PBM Benefit Type Notes Pharmacy N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A N/A Capsule Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Doxycycline Delayed-Release Capsule 40mg Capsule J8499 PBM D-Pennicillamine Oral Agent J3490 N/A* N/A Pharmacy *Oral chelation agents do not require precertification. Drisdol (ergocalciferol) Capsule, Liquid J3490, and J8499 N/A N/A Pharmacy N/A Duac (Clindamycin and Benzoyl Peroxide) Topical Duac CS (Clindamycin and Benzoyl Peroxide) Pharmacy N/A Topical Pharmacy Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A J3490 PBM J3490 Duexis (famotidine and ibuprofen) Tablet J8499 N/A Dulera (mometasone furoate/formoterol fumarate dihydrate) Inhaler J3490 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Step Therapy Guidelines: Dulera ©1996-2017, Oxford Health Plans, LLC Page 35 of 147 Effective 06/01/2017 Medication/Drug Duopa (carbidopa/ levodopa) Dosage Form Enteral Suspension Dupixent (dupilumab) Injection Duragesic (Brand Only) (fentanyl) Transdermal Patch CPT/HCPCS Code(s) Precertification Routing J3490 PBM J3590 PBM J3490 Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Duopa Benefit Type Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Dupixent Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. PBM Durlaza (aspirin) Capsule J8499 N/A N/A N/A Dutoprol Tablet J8499 N/A N/A Pharmacy Dyanavel XR (amphetamine) Oral suspension J8499 Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Dynavel XR Pharmacy N/A Precertification Guidelines: Botulinum Toxins A and B Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy* N/A Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Oxford Pharmacy N/A PBM Dymista (fluticasone (Flonase) Nasal Spray J3490 PBM Dynavel XR (amphetamine extended release) Oral Suspension J8499 PBM Dysport (abobotulinumtoxi n A) Injection J0586 Oxford’s Medical Management Ecoza (econazole nitrate topical foam 1%) Topical J3490 PBM Edex (alprostadil) Vial J0270 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes ©1996-2017, Oxford Health Plans, LLC Page 36 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Edluar (zolpidem) E.E.S. 400 (erythromycin ethylsuccinate) (brand) Tablet J8499 PBM Oral liquid J8499 PBM Effexor XR (venlafaxine) (brand only) Capsule J8499 PBM Egrifta (tesamorelin) Injection J8999 PBM Elaprase (idursulfase) IV Infusion, Injection J1743 N/A Elelyso (taliglucerase alfa) Injection J3060 Oxford’s Medical Management Elestat (epinastine HCL) Ophthalmic solution J3490 PBM Elidel (pimecrolimus) Topical J3490 PBM J1950, J9217, J9218 and J9219 PBM Eligard (leuprolide acetate) SQ Injection Emadine (emedastine difumarate) Ophthalmic Solution J3490 PBM Embeda (morphine sulphate and naltrexone hcl) Capsule J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Select Brand Medications Oxford Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Egrifta (tesamorelin) Pharmacy N/A Medical N/A N/A Precertification Guidelines: Enzyme Replacement Therapy (ERT) for Gaucher Disease Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Elidel (pimecrolimus) Pharmacy N/A Prior Authorization/ Notification Guidelines: Eligard (leuprolide acetate) Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Embeda Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 37 of 147 Effective 06/01/2017 Dosage Form Capsule or Trifold Pack CPT/HCPCS Code(s) Emend (fosaprepitant) IV Infusion J1453 Emflaza (deflazacort) Oral suspension J8499 PBM Empagliflozin / Metformin Tablet J3490 N/A Emverm (mebendazole) Chewable tablet J8499 PBM Medication/Drug Emend (aprepitant) Enablex (darifenacin) Tablets Precertification Routing Coverage Criteria/Guidelines J8501 N/A Injection J1438 Vaginal Insert Enstilar foam (calcipotriene/ betamethasone) Topical Foam Entocort EC (budesonide) (brand only) J3490 J3490 Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Enbrel (etanercept) Step Therapy: Enbrel Pharmacy N/A PBM Precertification Guidelines: Infertility Diagnosis and Treatment Pharmacy* *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A PBM PBM N/A Prior Authorization/Medical Necessity Guidelines: Emverm Capsule Pharmacy PBM N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Endometrin (progesterone) N/A Medical Enbrel (etanercept) Notes Pharmacy N/A J8499 Benefit Type ©1996-2017, Oxford Health Plans, LLC Page 38 of 147 Effective 06/01/2017 Medication/Drug Entresto (valsartan – sacubitril) Dosage Form Tablet CPT/HCPCS Code(s) J8499 Precertification Routing PBM Injection J3380 and J3490 Precertification Guidelines: o Entyvio (vedolizumab) o Specialty Medication Administration – Site of Care Review Guidelines Medical Hospital Outpatient Facility: Administration of Entyvio in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Pharmacy N/A Prior Authorization/ Notification Guidelines: Epanova Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: o Epclusa – CT and NJ o Epclusa – NY Pharmacy N/A Tablet J7508 PBM Epaned (enalapril) Powder for Oral Solution J8499 PBM Epanova (omega3-carboxylic acids) Capsule J8499 PBM Epclusa (sofosbuvir/ velpatasfir) Tablet Epi Quinn Micro (hydroquinone) Varies Epiduo (adapalene and benzoyl peroxide) Gel Epiduo Forte (adapalene and benzoyl peroxide) J8499 PBM J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. J3490 and J8499 N/A N/A Pharmacy N/A Pharmacy N/A Topical Gel Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes N/A Oxford’s Medical Management Envarsus XR (tacrolimus) Benefit Type Pharmacy Entyvio (vedolizumab) Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Entestro (valsartan-sacubitril) J3490 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 39 of 147 Effective 06/01/2017 Medication/Drug Epinephrine Pen Injection, 0.15mg and 0.3mg (generic Adrenaclick) Ergomar (ergotamine tartrate) Erivedge (vismodegib) Ertaczo (sertaconazole nitrate) Erythropoetin (EPO, Epoetin Alfa, Epogen, Procrit) Dosage Form Pen Injection CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines J0171 PBM Tablet Oral Cream Injection, SQ Injection J8499 J8999 J3490 Q4081ESRD OR J0885-nonESRD PBM PBM* Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy Pharmacy Capsule Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM N/A N/A Prior Authorization/ Notification Guidelines: Erivedge Pharmacy** Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Precertification Guidelines: Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Methoxy Polyethylene Glycol-Epoetin Beta Medical/ Pharmacy Prior Authorization/Medical Necessity Guidelines: Esbriet (pirfenidone) Pharmacy ©1996-2017, Oxford Health Plans, LLC *No precertification is required if dispensed by a retail pharmacy through the PBM. *Precertification is required if provided in a hospital or MD's office. *No precertification is required if dispensed by a retail pharmacy through the PBM. N/A* Esbriet (pirfenidone) Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. PBM Oxford’s Medical Management* Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type N/A Page 40 of 147 Effective 06/01/2017 Medication/Drug Esomeprazole Strontium Estradiol TD twice weekly patch (generic VivelleDot) estradiol vaginal tablet [Yuvafem (generic for Vagifem)] Estrostep FE (ethinyl estradiol and norethindrone) Dosage Form Capsule Transdermal Patch Vaginal tablet Pills Eucrisa (crisaborole) Topical Ointment Euflexxa (sodium hyaluronate) IntraArticular Injection Evekeo (amphetamine sulfate) Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy CPT/HCPCS Code(s) Precertification Routing J8499 N/A* Coverage Criteria/Guidelines N/A J3490 PBM J3490 S4993 PBM N/A J3490 PBM J7323 Oxford’s Medical Management* J8499 PBM Benefit Type N/A* Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Notes Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Prior Authorization/Medical Necessity Guidelines: Eucrisa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A * Precertification Guidelines: Sodium Hyaluronate Medical Precertification is not required in the office for Oxford's preferred products of Euflexxa, Synvisc or Synvisc-One (J7323 and J7325). Prior Authorization/ Notification Guidelines: Evekeo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 41 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Evista (raloxifene) (Brand only) Oral J8999 PBM Evotaz (atazanavir/ cobicistat) Tablet J8499 N/A Evzio (nalozone HCL injection) AutoInjector J3490 PBM Exalgo (hydromorphone) Tablet J8499 PBM Excelon Patch (rivastigmine) (brand) Transdermal patch Exforge (amlodipine valsartan) N/A Prior Authorization/Medical Necessity Guidelines: Evzio Prior Authorization/Medical Necessity Guidelines: Exalgo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Exjade Precertification Guidelines: o Exondys 51 o Specialty Medication Administration – Site of Care Review Guidelines J3490 PBM Tablet J3490 and J8499 Exforge HCT (amlodipine, hydrochlorothiazide and valsartan) Tablet J3490 and J8499 PBM Exjade (Deferasirox) Tablet J3490 PBM PBM Exondys 51 (eteplirsen) Intravenous Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3590 Oxford’s Medical Management Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Evista Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical Hospital Outpatient Facility: Administration of Exondys 51 in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Page 42 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Extavia (interferon B-1b) Injection J1830 or J3490 PBM Eylea (afibercept) Injection J0178 N/A Fabior (tazarotene) Topical J3490 PBM Fabrazyme® (agalsidase beta) IV Infusion, Injection J0180 N/A Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Extavia Step Therapy Guidelines: Extavia (interferon B-1b) Benefit Type Notes Pharmacy N/A N/A Prior Authorization/ Notification Guidelines: Fabior (tazarotene) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Medical N/A Pharmacy N/A N/A Medical N/A Pharmacy N/A Falessa Kit (birth control plus vitamin supplement) Tablet J8499 PBM Famvir (famciclovir) Tablet J8499 N/A N/A Pharmacy N/A Fanapt (iloperidone) Oral J8499 N/A N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) Pharmacy The Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Prior Authorization/ Notification Guidelines: Farydak Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Felbatol Pharmacy N/A Farxiga (depagliflozin) Tablets Farydak (panobinostat) Capsule J8999 PBM Felbatol (felbamate) Tablets and Oral Suspension J8499 PBM J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 43 of 147 Effective 06/01/2017 Medication/Drug Femara (letrozole) (brand only) Fenofibrate 43mg, 130mg (generic Antara) capsule Fenofibrate 48mg, 145mg (generic Tricor) Fenofibrate 50mg, 150mg (generic Lipofen) capsule Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Capsule J8499 PBM Tablet J8499 PBM Capsule J8499 PBM Fenoglide (fenofibrate) Tablet Fentanyl transdermal patch (37.5, 62.5 and 87.5 mcg/hr strengths only) Topical Patch J8499 PBM J3490 PBM Fentora (fentanyl buccal) Tablet J8499 PBM Ferriprox (Deferiprone) Tablet J3490 PBM Fertinex (urofollitropin) Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3355* and J3490 Precertification through Optum may be required* Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Fentora (fentanyl) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Ferriprox Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J3355 (urofollitropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs Page 44 of 147 Effective 06/01/2017 Medication/Drug Fetzima (Levomilnacipran) Dosage Form Capsule CPT/HCPCS Code(s) Precertification Routing J8499 PBM Tablet J8499 PBM Finacea 15% Foam (azelaic acid) Foam J3490 N/A Capsule J8499 PBM Capsule J8499 PBM Firazyr (icatibant) Injection J1744 PBM Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J9155 Oxford’s Medical Management* Step Therapy Guidelines: Fetzima Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Fioricet with Codeine 50mg/325mg/ 40mg/30mg (Brand Only) Firmagon Fibricor 35mg, 105mg (fenofibric acid) Fioricet with Codeine capsule 50mg/300mg/ 40mg/30mg Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Firazyr Precertification Guidelines: Gonadotropin Releasing Hormone Analogs ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Page 45 of 147 Effective 06/01/2017 Medication/Drug First Progesterone (progestin) Flebogamma (immune globulin Non-Lyophilized) Flector (diclofenac) Flomax (tamsulosin) (brand only) Dosage Form Varies CPT/HCPCS Code(s) Precertification Routing J3490 N/A Injection J1572 Patch J3490, J8499 Coverage Criteria/Guidelines Precertification Guidelines: Infertility Diagnosis and Treatment Precertification Guidelines: o Immune Globulin (IVIG) and SCIG o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oxford’s Medical Management PBM Capsule Flo-Pred (prednisolone) Suspension Floxin 0.3% Otic (ofloxacin) Otic Solution FlowTuss (hydrocodone/ guaifenesin) Oral solution Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J3490 and J8499 PBM PBM J3490 PBM J8499 PBM ©1996-2017, Oxford Health Plans, LLC Benefit Type Pharmacy* Notes *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 46 of 147 Effective 06/01/2017 Medication/Drug Flublok (Influenza Vaccine, Recombinant Hemagglutinin Antigens) FluMist (influenza virus vaccine (nasal)) Fluocinonide 0.1% cream (generic Vanos) Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Intramuscular Injection Q2033 N/A Nasal Spray 90660 N/A N/A Topical J3490 PBM Fluorouracil 0.5% Cream Topical J3490 PBM Fluticasone (topical) Topical J3490 PBM Focalin (dexmethylphenida te HCl) Capsule J8499 PBM Focalin XR (dexmethylphenida te HCl [extended release]) Folic Acid Capsule Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J8499 PBM N/A Medical Management Guidelines: o Preventive Care Services o Vaccines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Compounds and Bulk Powders Prior Authorization/ Notification Guidelines: Focalin Prior Authorization/ Notification Guidelines: Focalin XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Medical N/A Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the Member does not have vitamin/ supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Page 47 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Follistim AQ (follitropin beta) Injection S0128 Precertification through Optum* Forfivo XL (bupropion HCL) Tablet J8499 PBM Coverage Criteria/Guidelines Precertification Guidelines: Follicle Stimulating Hormone (FSH) Gonadotropins Prior Authorization/Medical Necessity Guidelines: Select Brand Medications Oxford Prior Authorization/Medical Necessity Guidelines: Fortamet (metformin extendedrelease) Prior Authorization/ Notification Guidelines: Teriparatide (Forteo) Prior Authorization/Medical Necessity Guidelines: Fortesta Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fortamet (metformin extended-release) Tablet J8499 PBM Forteo (teriparatide) Injection, SQ Injection J3110 PBM Fortesta (testosterone) Fragmin (dalteparin) Frova (frovatriptan) Benefit Type See Notes* Notes *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit. *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Gel J3490 PBM Injection J1950 N/A N/A Medical N/A Injection, SQ Injection J1645 N/A* N/A Pharmacy *No precertification is required if dispensed by a retail pharmacy or Mail Order through PBM. Pharmacy* **Precertification Note: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM** Supply Limit Guidelines: Triptans Supply Limits ©1996-2017, Oxford Health Plans, LLC Page 48 of 147 Effective 06/01/2017 Medication/Drug Fuzeon (enfuvirtide) Fycompa (perampanel) Dosage Form CPT/HCPCS Code(s) Precertification Routing Injection J3490 N/A Tablets J8499 PBM Gammagard® Liquid (immunoglobulin, Non-Lyophilized) Gammaplex (immunoglobulin, Non-Lyophilized) J1569 Injection Gamunex-C, Gammaked (immune globulin, Non-Lyophilized) Gattex (teduglutide [rDNA origin]) J1557 N/A Injection, SQ Injection J3490 J3490 PBM Gel-One (Hyaluronan) IntraArticular Injection J7324 Oxford’s Medical Management* Gel-Syn (sodium hyaluronate) IntraArticular Injection J7328 Oxford’s Medical Management Nail Laquer J3490 Precertification Guidelines: o Immune Globulin (IVIG) and SCIG o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Medical N/A Pharmacy N/A Pharmacy N/A J8499 PBM Generic Levetiracetam XR Tablet J8499 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Prior Authorization/ Notification Guidelines: Gattex Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Sodium Hyaluronate Medical *Precertification with review by a Medical Director or their Designee is required in all sites of service for J7321, J7324 and J7326. Precertification Guidelines: Sodium Hyaluronate Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Tablet N/A N/A PBM Generess FE (norethindrone/ ethinyl estradiol) Medical Pharmacy Topical gel Notes Prior Authorization/Medical Necessity Guidelines: Fycompa Oxford’s Medical Management PBM Benefit Type J1561 Gelnique (oxybutynin) Genadur Kit Coverage Criteria/Guidelines N/A ©1996-2017, Oxford Health Plans, LLC Page 49 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Genotropin (somatropin) Injection J2941 PBM Genotropin MiniQuick (somatropin) Injection J2941 PBM Genvisc 850 (sodium hyaluronate) IntraArticular Injection J7320 Oxford’s Medical Management Genvoya (elvitegravir/ cobicistat/ emtricitabine/ tenofovir alafenamide) Tablet J8499 PBM Geodon (ziprasisdone) (brand only) Capsule Gialax Kit (polyethylene glycol) Orol solution J8499 PBM Gilenya (fingolimod) Injection J3490 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy N/A Pharmacy N/A N/A Step Therapy Guidelines: Genvoya Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Gilenya Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A J8499 Pharmacy Medical PBM Tablet Notes Precertification Guidelines: Sodium Hyaluronate PBM Giazo (balsalazide disodium) Benefit Type J8499 Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Genotropin (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 50 of 147 Effective 06/01/2017 Medication/Drug Gilotrif (afatinib) Glatopa (Glatiramer 20mg [generic Copaxone]) Dosage Form Tablets Injection CPT/HCPCS Code(s) Precertification Routing J8999 PBM* J3490 PBM Coverage Criteria/Guidelines Glucophage XR (metformin extended-release [brand only]) Glumetza (metformin extended-release) Oral, Varies S0088 PBM* Prior Authorization/ Notification Guidelines: Gilotrif (Afatinib) Pharmacy** Prior Authorization/ Notification Guidelines: Glatopa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy N/A Tablet J8499 PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Gleevec (imatinib mesylate) Benefit Type Prior Authorization/ Notification Guidelines: Gleevec Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Glucophage XR (metformin extended-release [brand only]) Prior Authorization/Medical Necessity Guidelines: Glumetza (metformin extendedrelease) ©1996-2017, Oxford Health Plans, LLC Page 51 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Glyxambi (empagliflozin / linagliptin) Tablet PBM Gonal-F / Gonal-f RFF (follitropin alfa) IM or SQ Injection Gonitro (nitroglycerin) Sublingual powder Gralise (gabapentin) J8499 Capsule S0126 J3490 J3490 and J8499 Precertification through Optum* Precertification Guidelines: Follicle Stimulating Hormone (FSH) Gonadotropins Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Grastek (Timothy Grass Pollen Allergen Extract) Step Therapy Guidelines: Halog PBM PBM Granix (tbofilgrastiim) Injection Grastek (Timothy Grass Pollen Allergen Extract) Sublingual Tablet J8499 PBM Halog 0.1% cream (halcinonide) Cream J3490 PBM Halog 0.1% ointment (halcinonide) Ointment J3490 PBM Halotestin (fluoxymesterone) Tablet J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) PBM Step Therapy Guidelines: Halog N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Pharmacy Notes The Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. See Notes* *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit.* *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 52 of 147 Effective 06/01/2017 Medication/Drug Harvoni™ (ledipasvir/ sofosbuvir) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: o Harvoni - CT/NJ o Harvoni - NY Benefit Type Notes Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) J0725 requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Injection J0725* and J3490 Precertification through Optum may be required* Hectorol (doxercalciferol) Capsule J8499 N/A N/A Pharmacy N/A Injection J1270 N/A Medical N/A Helidac (bismuth subsalicylate) Capsules/ Tablets J8499 PBM Pharmacy N/A Hemangeol Oral solution (propranolol hydrochloride) Oral Solution J8499 PBM Pharmacy N/A J7175 J7178 J7179 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 See Notes* N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: o Assisted Administration of Clotting Factors and Coagulant Blood Products o Clotting Factors and Coagulant Blood Products o Eloctate™ (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business (Medical Benefit) o Home Health Care Prior Authorization/Medical See Notes* Effective 12/01/2013 for NY LOBS (excluding Healthy NY and NY Individual Plans) and New Jersey Large and Small Groups: *Precertification: Is required through Oxford for self-administered clotting factor drugs (including Eloctate) provided by a Hemophilia Treatment Center including (Medical benefit applies): NY Presbyterian Hospital- HCG (chorionic gonadotropin) HEMOPHILIA DRUGS Brand Names Adynovate, Advate, Afstyla, Alphanate, Alphanine SD Alprolix Bebulin, Benefix, Coagadex, Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Page 53 of 147 Effective 06/01/2017 Medication/Drug Corifact Eloctate Feiba NF Feiba VH Helixate FS**, Hemofil-M, Humate-P, Idelvion, Ixinity** Koate-DVI, Kogenate FS, Kovaltry Monoclate-P Mononine Novoeight Novoseven RT Nuwig Obizur Profilnine SD Recombinate, RiaSTAP Rixubis Tretten Vonvendi Wilate Xyntha Xyntha Solofuse Dosage Form Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy CPT/HCPCS Code(s) J7189 J7190 J7192 J7193 J7194 J7195 J7198 J7199 J7200 J7201 J7202 J7205 J7207 J7209 Precertification Routing Coverage Criteria/Guidelines Necessity Guidelines: o Advate o Adynovate o Eloctate Medical Necessity o Helixate FS o Ixinity o Recombinate o Xyntha Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications** ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Weill Cornell Center Mount Sinai Medical Center Long Island Jewish Medical Center Is required for selfadministered Eloctate when covered under the pharmacy benefit, with precertification through the PBM. Is NOT required for all other self-administered clotting factor drugs (except Eloctate) obtained through any specialty designated pharmacy (Pharmacy benefit applies). Is required if assisted administration (provider’s office, clinic, home, etc). Eloctate is covered under the medical benefit, precertification obtained through Oxford. For Connecticut LOB Member’s regardless of date of service: *Self-administered clotting factor drugs (except Eloctate) do not require pre-certification and are covered under the medical benefit. Self-administered Eloctate requires precertification through Oxford and is covered under the medical benefit. *If the member requires assisted administration of their clotting factor drugs, precertification is required in all sites of service and is covered under the medical benefit. For assisted administration in the home, please refer to Home Health Care. *HMO Members: If drugs are Page 54 of 147 Effective 06/01/2017 Medication/Drug HepaGam B (hepatitis B immune globulin [human]) Heparin Dosage Form Injection Injection CPT/HCPCS Code(s) Precertification Routing J1571 and J1573 N/A J1642 or J1644 N/A Coverage Criteria/Guidelines N/A N/A Herceptin (trastuzumab) Hetlioz (tasimelteon) Injection Capsule J9355 J8499 Oxford’s Medical Management* PBM Hizentra (immune globulin) Horizant (gabapentin, enacarbil) Injection J1559 Oxford’s Medical Management Tablet J8499 PBM Humatrope (somatropin) Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J2941 PBM eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Precertification Guidelines: Maximum Dosage Policy Prior Authorization/Medical Necessity Guidelines: Hetlioz Precertification Guidelines: o Immune Globulin (IVIG) and SCIG o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Humatrope (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes requested or supplied through a non-par vendor and authorization is not approved, these services will not be reimbursed by Oxford. Medical N/A See Notes* *Pharmacy Benefit: If dispensed by a retail pharmacy or Mail Order through PBM. *Medical Benefit: If provided in a hospital, MD's office, or in conjunction with Home Health Care. Medical *For Oncology and NonOncology Use: Precertification is required Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Page 55 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing S0122* and J3490 Precertification through Optum may be required Humegon (menotropins) Injection Humira (adalimumab) Injection, SQ Injection J0135 PBM Hyalgan (sodium hyaluronate) IntraArticular Injection J7321 Oxford’s Medical Management Hycamtin (topotecan hydrochloride) Oral Hycofenix (hydrocodone/ pseudoephedrine/ guaifenesin) Oral solution hydrocortisone 1% ointment in absorbase J8705 J3490 PBM* Coverage Criteria/Guidelines Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 Precertification Guidelines: Infertility Diagnosis and Treatment Pharmacy/ Medical** Prior Authorization/ Notification Guidelines: Humira (adalimumab) Pharmacy N/A Precertification Guidelines: Sodium Hyaluronate Medical N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Hycamtin Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM PBM Notes Precertification Note: *HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Benefit Note: **Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Ointment Benefit Type ©1996-2017, Oxford Health Plans, LLC Page 56 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Hydromorphone ER Tablet J8499 PBM Hysingla ER (hydrocodone bitartrate) tablet J8499 PBM Hytakerol Capsule (dihydrotachysterol) J8499 N/A Ibrance (palbociclib) J8499 PBM Capsules N/A Iclusig (ponatinib) Oral J8999 PBM* Ilaris (canakinumab) Injection Ilevro (nepafenac) Ophthalmic Suspension Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J0638 N/A PBM Prior Authorization/ Notification Guidelines: Ibrance Prior Authorization/ Notification Guidelines: Iclusig Step Therapy Guidelines: Iclusig (ponatinib) N/A J3490 Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Hydromorphone ER Prior Authorization/Medical Necessity Guidelines: Hysingla ER Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Medical N/A Pharmacy N/A Page 57 of 147 Effective 06/01/2017 Medication/Drug Dosage Form Imatinib (generic Gleevec) Oral Imbruvica (ibrutinib) Capsule Imitrex (sumatriptan) Imitrex (sumatriptan) (brand only) Nasal Spray Tablet CPT/HCPCS Code(s) Precertification Routing S0088 and J8999 N/A J8499 PBM J3490, J8499 and J3030 J8499 PBM** PBM Coverage Criteria/Guidelines N/A Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3030 PBM Prior Authorization/ Notification Guidelines: Imbruvica Supply Limit Guidelines: Triptans Supply Limits Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Imitrex (sumatriptan) (brand only) Pharmacy Benefit Type ©1996-2017, Oxford Health Plans, LLC Notes Precertification Note: Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy* **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. *NJ Plans do not require precertification. *Benefit Note: *New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Pharmacy N/A Pharmacy N/A Page 58 of 147 Effective 06/01/2017 Medication/Drug Immune Globulin (IVIG and SCIG) IVIg: Bivigam Carimune NF Gammaplex® Flebogamma® Flebogamma® DIF Gammagard® Liquid Gammagard® S/D Gammaked™ Gamunex®-C Octogam® Privigen® Dosage Form CPT/HCPCS Code(s) Precertification Routing IV Infusion J1459 J1556 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1575 J1599 Oxford’s Medical Management Impavido (miltefosine) Tablet J8499 PBM Incivek (telaprevir) Tablet J8499 PBM Increlex (mecasermin) SQ Injection J2170 PBM Incruse Ellipta (umeclidinium) Inhalation Powder J3490 N/A SCIG: Gammagard® Liquid Gammaked™ Gamunex®-C Hizentra® HyQvia Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Precertification Guidelines: o Immune Globulin (IVIG and SCIG) o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Prior Authorization/ Notification Guidelines: Impavido Prior Authorization/ Notification Guidelines: Incivek Prior Authorization/Medical Necessity Guidelines: Increlex (mecasermin) N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 59 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Inflectra (infliximab) Intravenous J1745 Oxford’s Medical Management* Inlyta (axitinib) Oral J8999 PBM* Innohep (tinzaparin) Injection, SQ Injection J1655 N/A* Insulins (Novolin 70/30, Novolog pens and vials, Novolog Mix 70/30 pens and vials, Apidra, Apidra Solostar, Novolin N, Novolin R) Injection Intermezzo (zolpidem tartrate) Sublingual Tablet PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Medical Notes *Precertification is required in all sites of service. Hospital Outpatient Facility: Administration of Inflectra in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy *No precertification is required if dispensed by a retail pharmacy or Mail Order through PBM Prior Authorization/ Notification Guidelines: Insulin* Step Therapy Guidelines: Insulin Pharmacy *The Prior Authorization/ Notification Guidelines: Insulin policy applies to New York and Connecticut plans and products. The Step Therapy: Insulin policy applies to New Jersey plans and products. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Inlyta N/A J1815 Precertification Guidelines: o Infliximab (Remicade and Inflectra) o Maximum Dosage Policy o Specialty Medication Administration – Site of Care Review Guidelines Benefit Type ©1996-2017, Oxford Health Plans, LLC Page 60 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Intron-A (interferon Alfa2b) Injection J9212 PBM* Intuniv (guanfacine) (brand only) Tablet J8499 PBM Invega (paliperidone) Injection J3490 N/A Invega (paliperidone) (brand) N/A Tablet J8499 PBM Invokana (canagliflozin) Tablet J8499 PBM Irenka (duloxetine) Capsule J8499 PBM Iressa (gefitinib) Tablet J8999 PBM Jadenu (defirasirox) Tablets J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Prior Authorization/ Notification Guidelines: Intron-A (interferon alpha-2b) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Iressa Prior Authorization/ Notification Guidelines: Jadenu ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy *For Oncology and NonOncology use: Precertification is required. Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy The Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Pharmacy N/A Pharmacy NA Pharmacy N/A Page 61 of 147 Effective 06/01/2017 Medication/Drug Jakafi (ruxolitinib) Jalyn (dutasteride and tamsulosin) Dosage Form Oral Capsule CPT/HCPCS Code(s) Precertification Routing J8999 PBM* J3490 and J8499 Coverage Criteria/Guidelines Janumet XR (sitagliptin and metformin hydrochloride, extended release) Tablet J3490 Prior Authorization/ Notification Guidelines: Jakafi Pharmacy** Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy The Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) policy applies to New Jersey plans and products. Pharmacy The Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) policy applies to New Jersey plans and products. PBM PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Janumet (sitagliptin and metformin hydrochloride) Benefit Type PBM Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) ©1996-2017, Oxford Health Plans, LLC Page 62 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Januvia (sitagliptin) Tablet J3490 PBM Jardiance (empagliflozin) Tablet Jentadueto XR (linagliptin / metformin) Extended release tablet J8499 N/A Jublia (efinaconazole) Topical J3490 PBM Juxtapid (lomitapide) Capsule J8499 PBM Kadian (morphine sulfate extended release) Capsule J8499 PBM Kalbitor (ecallantide) IV Infusion J1290 N/A Kalydeco (ivacaftor) Tablet J8499 PBM Kapvay (clonidine hydrochloride) J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) N/A Pharmacy Notes The Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) policy applies to New Jersey plans and products. Pharmacy The Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Jublia Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Juxtapid Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Kadian Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A N/A Tablet Prior Authorization/ Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) Benefit Type Prior Authorization/Medical Necessity Guidelines: Kalydeco Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 63 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Karbinal ER (carbinoxamine maleate) Oral Suspension Kenalog Spray (triamcinolone) (brand) Topical Spray J3490 PBM Keppra (levatiricetam) Injection J1953 N/A Keppra (levetiracetam) Tablet J8499 PBM Keppra XR (levetiracetam extended release[XR]) Tablet J8499 PBM Keralac 47% cream (urea) Topical J8499 PBM J3490 J3490 PBM Kerydin (tavaborole) Topical J3490 PBM Ointment J3490 and J8499 J3490 PBM Keveyis (dichlorphenamide ) Tablet J8499 N/A Khedezla (desvenlafaxine extended release) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy PBM Pharmacy N/A Medical N/A Prior Authorization/Medical Necessity Guidelines: Keppra XR Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Kerydin Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A J8499 N/A N/A Tablet Pharmacy Pharmacy PBM Topical Notes Prior Authorization/Medical Necessity Guidelines: Keppra Ketodan Combination Package (ketoconazole) Benefit Type Topical Ketocon (ketoconazole) N/A PBM Keralyt Scalp Kit (salicylic acid) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Keveyis Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 64 of 147 Effective 06/01/2017 Medication/Drug Kineret (anakinra) Dosage Form Injection, SQ Injection CPT/HCPCS Code(s) J3490 Precertification Routing PBM Kitabis Pak (tobramycin) Inhalation Solution J3490 PBM Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Kineret (anakinra) Prior Authorization/ Notification Guidelines: Kitabis Pak Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Korlym Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy* *NJ Small Members should refer to their certificate of coverage for precertification and quantity limit guidelines. Medical N/A Pharmacy N/A Pharmacy N/A J3490 and J8499 PBM Injection J2507 N/A Kuvan (sapropterin dihydrochloride) Tablet J8499 PBM Kynamro (Mipomersen Sodium) SQ Injection J3490 PBM IV Injection J1626 N/A N/A Medical N/A Tablet, Oral Solution Q0166 and J8499 N/A N/A Pharmacy N/A Korlym (mifepristone) Oral Krystexxa (pegloticase) Kytril (granisetron hydrochloride) Lamictal (lamotrigine) Tablet J8499 PBM Lamictal ODT (lamotrigine orally disintegrating tablets) Tablet J8499 PBM Lamictal XR (lamotrigine extended release) Tablet J8499 PBM Lamisil (terbinafine hydrochloride) Tablet J8499 N/A Lamotrigine XR Tablet J3490 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy N/A Prior Authorization/ Notification Guidelines: Kuvan (sapropterin dihydrochloride) Prior Authorization/Medical Necessity Guidelines: Kynamro™ Prior Authorization/Medical Necessity Guidelines: Lamictal Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Lamictal ODT Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Lamictal XR Pharmacy N/A N/A N/A Pharmacy N/A N/A Prior Authorization/Medical Necessity Guidelines: Lamotrigine XR ©1996-2017, Oxford Health Plans, LLC Page 65 of 147 Effective 06/01/2017 Medication/Drug Lantus (insulin glargine) Dosage Form CPT/HCPCS Code(s) Precertification Routing Injection J3490 PBM Lantus Solostar (insulin glargine) Pen J3490 PBM Lazanda (fentanyl nasal spray) Nasal Spray J3490 PBM Latuda (lurasidone) Tablet Lemtrada (alemtuzumab) Infusion Lenvima (lenvatinib) Capsules J8499 PBM J9010 and J9999 Oxford’s Medical Management* J8999 PBM Step Therapy Guidelines: Latuda* eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Precertification Guidelines: Lemtrada (Alemtuzumab) (for non-oncology indications) Prior Authorization/ Notification Guidelines: Lenvima Step Therapy Guidelines: Lescol Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Letairis Lescol XL (fluvastatin) (brand and generic) capsule J8499 PBM Letairis (ambrisentan) Tablet J3490 PBM Leukine (sargramostim) Injection, SQ Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J2820 N/A Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Lazanda N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy *Step Therapy coverage criteria is for groups on the Essential PDL only. More information about if this program applies can be found on myuhc.com or by calling customer service. Medical *For Oncology and NonOncology Use: Precertification is required. Pharmacy N/A Pharmacy N/A Pharmacy N/A See Notes* *Pharmacy Benefit: If dispensed by a retail pharmacy or Mail Order through PBM. *Medical Benefit: If provided in a hospital, MD's office, or in conjunction with Home Health Care. Page 66 of 147 Effective 06/01/2017 Medication/Drug Leuprolide Acetate (subcutaneous) (Eligard), 1mg/0.2mL Dosage Form Injection CPT/HCPCS Code(s) Precertification Routing J9218 PBM* Levalbuterol nebs (generic Xopenex nebs) Inhalation J8499 PBM Levitra (vardenafil HCI) Tablet J3490 PBM Prior Authorization/ Notification Guidelines: Leuprolide Acetate Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Oxford Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lexapro (escitalopram) (brand only) Tablet J8499 PBM Lexiscan (regadenoson) IV Infusion J2785 N/A Librax (chlordiazepoxide / clidinium) (brand) Coverage Criteria/Guidelines N/A Capsule J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy *For Oncology and NonOncology Use: Precertification is required. Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Lidoderm (lidocaine) Topical J3490 PBM Lidorx (lidocaine hydrochloride) Topical Gel J3490 N/A N/A Pharmacy N/A Lidovin 3.95% (lidocaine) Topical Cream J3490 N/A N/A Pharmacy N/A Linzess (linaclotide) Capsule J3490 PBM Lipitor (brand only) (atorvastatin) Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/ Notification Guidelines: Linzess (Linaclotide) Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 67 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Lipofen (fenofibrate) Capsule J8499 PBM Liptruzet (ezetimibe and atorvastatin) Tablet J8499 N/A Livalo (pitavastatin) tablet J8499 PBM Lo Minastrin FE (ethinyl estradiol / norethindrone) Tablet J8499 Pill S4993 N/A N/A Benefit Type Pharmacy N/A Pharmacy N/A Step Therapy Guidelines: Livalo Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Lonsurf Loestrin/FE (ethinyl estradiol and norethindrone) Lodosyn (carbidopa) (brand) Locoid Lipocream & Locoid Lotion (hydrocortisone butyrate) Lofibra 54mg, 160mg (Brand only) (fenofibrate) Tablet J8499 PBM Topical J3490 PBM Tablet J8499 PBM Lofibra 67, 134, 200mg (fenofibrate) Tablet J8499 PBM Lonsurf (trifluridine/ tipiracil) Tablet J8999 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes PBM Lo/Ovral (ethinyl estradiol and norgestrel) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 68 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Loprox Shampoo (brand) Shampoo Loprox Suspension (ciclopirox) Topical Suspension Loprox 0.77% cream (ciclopirox) Topical cream J3490 PBM 95251 PBM J3490 PBM Lorzone (chlorzoxazone) Tablet Lotemax Gel (loteprednol etabonate) Ophthalmic Gel J8499 PBM J3490 PBM Lotronex (alosetron) (brand) Tablet J8499 N/A Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Lotronex (Alosteron) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Lovaza Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Lovaza Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy FDA approved only for use in women. Pharmacy N/A Pharmacy N/A Lovaza (Brand Only) (omega-3acid ethyl esters) Capsule J8499 PBM Lovaza (Generic) (omega-3-acid ethyl esters) Capsule J8499 PBM Lovenox (enoxaparin) Injection, SQ Injection J1650 N/A N/A Pharmacy N/A Lucentis (ranibizumab) Injection J2778 N/A N/A Medical N/A Lunelle (medroxyprogester Injection J3490 N/A See Notes* *Pharmacy Benefit if dispensed by a retail pharmacy. Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Guidelines: Contraceptives ©1996-2017, Oxford Health Plans, LLC Page 69 of 147 Effective 06/01/2017 Medication/Drug one acetate and estradiol cypionate) Lunesta (eszopicione) (brand only) Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Tablet J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Pharmacy Injection J1950, J9217, and J9219 Oxford’s Medical Management* eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Precertification Guidelines: Gonadotropin Releasing Hormone Analogs Lupron Depot 7.5mg 22.5 (3 month supply of 7.5mg dose) 30mg (4 month dose of 7.5mg) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy N/A *Precertification Note: For Oncology Use precertification is required. For Non-Oncology Use precertification through Oxford Medical Management is required for all indications for: Lupron Depot Pediatric (all dosages) and Lupron Depot 3.75mg, 11.25mg Lupron, Lupron-3, Lupron-4, Lupron Depot, Lupron Depot Pediatric Lupron Implant (Leuprolide Acetate): Lupron Depot 3.75mg, 11.25 (3 month supply of 3.75 dose) Notes *Medical Benefit if provided in an MD's office. *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Medical** Precertification is required for all dosages of Lupron Depot for the diagnosis of gender dysphoria; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Precertification is not required for Lupron Depot 7.5mg, 22.5mg, and 30mg for the diagnosis of Prostate Cancer. ©1996-2017, Oxford Health Plans, LLC Page 70 of 147 Effective 06/01/2017 Medication/Drug Lupron DepotPediatric: 7.5mg, 11.25mg, 15mg Luxiq foam (betamethasone valerate) Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Foam J3490 PBM Luzu (luliconazole) Cream J3490 PBM Lynparza (olaparib) Capsule J8999 PBM Lyrica (pregabalin) Tablet J8499 PBM Macugen (pegaptanib sodium) Injection J2503 N/A Makena (17-alphahydroxyprogesterone caproate or 17P) Injection J1725 and J2675 Oxford’s Medical Management Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Lynparza Step Therapy Guidelines: Lyrica N/A Precertification Guidelines: 17-Alpha-Hydroxyprogesterone Caproate (Makena and 17P) ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes New Jersey Small Members should refer to their certificate of coverage for precertification guidelines. **Benefit Note: For Connecticut Large and Small Plans: Infertility drugs will be covered under the Pharmacy Benefit if the Member has pharmacy coverage. If the Member does not have pharmacy coverage, infertility drugs will be covered under the Medical Benefit. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Medical N/A Page 71 of 147 Effective 06/01/2017 Medication/Drug Materna, Natalcare, Natalins Rx, Niferex-PN, Prenate 90, Prenatal Plus, Prenatal Rx, and Stuartnatal Plus Dosage Form Tablet CPT/HCPCS Code(s) Precertification Routing S0197 N/A Coverage Criteria/Guidelines N/A Maxalt and MaxaltMLT (brand only) Tablet J8499 PBM Mekinist (Trametinib) Tablet J8499 PBM Injection Mepron suspension (Brand Only) (atovaquone) Oral Suspension J8499 PBM Metadate CD ([controlled release brand only) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy S0122* and J3490 Precertification through Optum* Menopur (Menotropins) Benefit Type Pharmacy* Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Mekinist (Trametinib) Notes *Coverage is limited to Members with coverage for prenatal vitamins through their prescription drug plan. If the Member does not have prenatal vitamin coverage through their prescription drug plan then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Precertification Guidelines: Human Menopausal Gonadotropins (hMG) Pharmacy/ Medical** *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Metadate CD Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 72 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Metadate ER Tablet J8499 PBM Methitest (methyltestosterone) Tablet J8499 N/A Methylin and Methylin ER (methylphenidate) Capsule J8499 PBM Methylphenidate extended-release capsule (generic Metadate CD) Capsule J8499 PBM Methylphenidate extended-release tablet (generic Concerta) Metoprolol 37.5mg, 75mg metoprolol succinate/ hydrochlorothiazid e (Dutoprol Authorized Generic) Metozolv ODT (metoclopramide hydrochloride) Metrodin (urofollitropin) Tablet J8499 PBM N/A J8499 J8499 Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J3355* and J3490 N/A Pharmacy N/A N/A Prior Authorization/ Notification Guidelines: Metadate CD Pharmacy N/A Prior Authorization/ Notification Guidelines: Concerta Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J3355 (urofollitropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug PBM PBM PBM Precertification through Optum may be required* Pharmacy Pharmacy Tablet Notes Prior Authorization/ Notification Guidelines: Methylin and Methylin ER tablet Benefit Type Tablet Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Metadate ER Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Page 73 of 147 Effective 06/01/2017 Medication/Drug Metrogel 0.75% Vaginal (metronidazole) (brand) Metrogel 1% (metronidazole) Dosage Form CPT/HCPCS Code(s) Precertification Routing Topical J3490 PBM Topical J3490 PBM Metronidazole 1% gel (generic Metrogel 1%) Topical J3490 PBM Metvixia (Methyl aminolevulinate) Topical J7309 N/A Micardis (Brand Only) (telmisartan) Tablet J8499 PBM J8499 PBM Topical cream PBM Micronor (norethidrone) Pills S4993 N/A Mifeprex Oral S0190 Oxford’s Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Micardis HCT (Brand Only) (telmisartan/ Tablet hydrochlorothiazide) Micort-HC 2.5% cream (hydrocortisone acetate) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Precertification Guidelines: Medical* Certain groups may exclude ©1996-2017, Oxford Health Plans, LLC Page 74 of 147 Effective 06/01/2017 Medication/Drug (mifepristone) Migranal (dihydroergotamine) (brand) Dosage Form CPT/HCPCS Code(s) Precertification Routing Medical Management Nasal Spray J3490 PBM Minastrin 24 FE (norethindrone acetate and ethinyl estradiol/ferrous fumarate) Capsules J8499 PBM Minocin (minocycline) Injection J2265 N/A Minocin 50mg, 75mg and 100mg (minocycline hcl) Mirapex ER (pramipexole dihydrochloride) Mircera (methoxy polyethylene glycol-epoetin beta) Coverage Criteria/Guidelines Mifeprex® (Mifepristone, RU486) Capsule J8499 PBM Tablet Injection J8499 PBM J3490 Oxford’s Medical Management* Misoprostol Tablet S0191 Oxford’s Medical Management Mitigare (colchicine) Capsule J8499 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes these services from coverage if such coverage would be contrary to the Group's bona fide religious tenets. Please refer to the Member's certificate of coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Medical N/A Medical* Certain groups may exclude these services from coverage if such coverage would be contrary to the Group's bona fide religious tenets. Please refer to the Member's certificate of coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Pharmacy N/A N/A Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa and Methoxy Polyethylene Glycol-Epoetin Beta Precertification Guidelines: Abortions (Therapeutic and Elective) N/A ©1996-2017, Oxford Health Plans, LLC Page 75 of 147 Effective 06/01/2017 Medication/Drug Moderiba Tablet (ribavirin) Moderiba Pak (ribavirin) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Tablet J8499 PBM Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Modicon (ethinyl estradiol and norethindrone) Pills S4993 N/A Molindone Tablet J8499 N/A N/A Pharmacy N/A Momexin Combo Package (mometasone furoate) Cream J3490 N/A N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Monodox (doxycycline) (brand only) Capsule J8499 PBM Morgidox (doxycycline) Capsule J8499 N/A Morgidox Kit / Combo Pkg (doxycycline plus cleanser) Capsule/ Topical J8499 PBM Morphine sulfate Extended Release Pellets (generic Kadian) Tablets J8499 N/A Movantik (naloxegol) Tablet J8499 PBM Mozobil (plerixafor) Injection J2562 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Prior Authorization/ Notification Guidelines: Movantik N/A ©1996-2017, Oxford Health Plans, LLC Page 76 of 147 Effective 06/01/2017 Medication/Drug MS Contin Dosage Form Tablet CPT/HCPCS Code(s) J8499 Precertification Routing PBM Multaq (dronedarone) Tablet J8499 PBM Muse (alprostadil) Pellet J0275 PBM Myalept (metreleptin) Injection J3490 PBM Myobloc (rimabotulinumtoxin B) Injection J0587 Oxford’s Medical Management Myorisan (isotretinoin) Capsule J8499 PBM Myozyme (alglucosidase alfa) IV Infusion, Injection J0220 N/A Tablets J8499 PBM Mysoline (primidone) Tablets J8499 PBM Mytesi (crofelemer) Oral J8999 PBM Naftin 2% gel (naftifine hydrochloride) Namenda XR (Memantine Hydrochloride) J3490 J3490 Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Myorisan Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A N/A N/A PBM PBM PBM N/A N/A Capsule Pharmacy Medical Topical gel Notes Precertification Guidelines: Botulinum Toxins A and B Cream Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Oxford Prior Authorization/Medical Necessity Guidelines: Myalept (metreleptin) Benefit Type Myrbetriq (mirabegron) Naftin 1% (naftifine hcl) Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: MS Contin Prior Authorization/ Notification Guidelines: Multaq Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Mysoline Prior Authorization/ Notification Guidelines: Mytesi Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 77 of 147 Effective 06/01/2017 Medication/Drug Namzaric (memantine hydrochloride) Naprelan (Naproxen Sodium) Naprelan CR (Dose Card) (Naproxen Sodium) Narcan Nasal Spray (naloxone) Nasonex (mometasone furoate monohydrate) Dosage Form CPT/HCPCS Code(s) Precertification Routing Capsule J8499 PBM Tablet J3490 and J8499 PBM Tablet J3490 and J8499 N/A N/A Nasal Spray J3490 PBM Nasal Spray J3490 PBM Natesto (testosterone nasal gel) Nasal Gel J3490 PBM Natpara (parathyroid hormone) Injection J3490 PBM Natrecor (nesiritide) Injection J2325 N/A Natroba (spinosad) (brand only) Topical Suspension Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Natesto Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Natpara N/A J3490 Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Nava-SC (hydroquinone) Varies J3490 PBM N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. NeoBenz Micro (benzoyl peroxide) Liquid J3490 PBM N/A Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 78 of 147 Effective 06/01/2017 Medication/Drug Neo-Synalar (neomycin sulfate and fluocinolone) Dosage Form CPT/HCPCS Code(s) Precertification Routing Topical J3490 PBM Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Neo-Synalar kit (neomycin sulfate and fluocinolone) Topical J3490 PBM Neuac 1.2%-5% (clindamycin phosphate and benzoyl peroxide) Topical J3490 N/A N/A Pharmacy N/A Neuac 1.2%-5% kit (clindamycin phosphate and benzoyl peroxide) Topical J3490 N/A N/A Pharmacy N/A See Notes* *Pharmacy Benefit: When dispensed by a retail pharmacy and administered in the home, without any other homecare services. *Medical Benefit: When provided in a hospital or MD's office. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications See Notes* *Pharmacy Benefit: When dispensed by a retail pharmacy and administered in the home, without any other homecare services. *Medical Benefit: When provided in a hospital or MD's office. Prior Authorization/Medical Necessity Guidelines: Neurontin Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Nexavar Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Neulasta (pegfilgrastim) Injection, SQ Injection J2505 N/A Neupogen (filgrastim) Injection, SQ Injection J1442 PBM Neurontin (gabapentin) Capsules, Tablets or Oral Solution J8499 PBM Nevirapine extended release (nevirapine) Nexavar (sorafenib tosylate) Tablet J8499 PBM Tablet J8999 PBM* Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Guidelines: Maximum Dosage Policy ©1996-2017, Oxford Health Plans, LLC Page 79 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Benefit Type Notes Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Nexavir (kutapressin) Injection J3490 N/A N/A Medical N/A Nexiclon XR (clonidine extended release) Tablet, Suspension J8499 N/A N/A Pharmacy N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Nexium (esomeprazole) Capsule J8499 N/A Nexium Suspension (esomeprazole) Suspension J8499 PBM Nicazeldoxy 30 kit (Doxycycline plus MVI) N/A Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 80 of 147 Effective 06/01/2017 Medication/Drug Nicotine OTC products: nicotine gum (e.g., Nicorette, Thrive), nicotine lozenge (e.g., Commit, Nicorette), nicotine patch (e.g., Nicoderm CQ), Nicotrol Inhaler (nicotine inhalation system), Nicotrol NS (nicotine nasal spray) Dosage Form Transdermal Patch / Gum / Lozenge CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines A9150 PBM Nicotrol Inhaler (nicotine) Inhalation System J3490 PBM Nicotrol NS (nicotine) Varies J3490 PBM Niferex (iron polysaccharide) or Niferex 150 Forte Capsule A9152 and A9153 N/A Ninlaro (ixazomib) Capsule J8999 PBM Nitroglycerin spray (generic nitrolingual) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform N/A Spray Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform Prior Authorization/ Notification Guidelines: Ninlaro Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Benefits for Tobacco Cessation for Health Care Reform apply to all plans subject to health care reform Pharmacy Pharmacy* Benefits for Tobacco Cessation for Health Care Reform apply to all plans subject to health care reform Pharmacy* Benefits for Tobacco Cessation for Health Care Reform apply to all plans subject to health care reform Pharmacy* *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Page 81 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Nitrolingual Pump Spray (nitroglycerin) Spray J8499 PBM Norditropin AQ (Somatropin) Injection J2941 PBM Norditropin (Somatropin) Injection Norditropin FlexPro (somatropin) Pen Injection J2941 PBM J2941 PBM Norditropin NordiFlex (somatropin) Pen Injection J2941 PBM Noritate (metronidazolel) Cream J3490 PBM Northera (droxidopa) Capsule J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Norditropin (somatropin) Prior Authorization/Medical Necessity Guidelines: Norditropin (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: NordiFlex (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Northera ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 82 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing J0725* and J3490 Precertification through Optum may be required* J8499 N/A Novarel (chorionic gonadotropin) Injection Noxafil (posaconazole) Tablet Nucala (mepolizumab) Subcutaneo us injection Nucynta ER (tapentadol extended release) Tablet J8499 PBM Nuplazid (pimavanserin tartrate) Tablet J8499 N/A Nutritonal Therapy, Formula and Specialized Foods, Parenteral Nutrition Therapy IV infusion, Oral Tube Feed Varies Oxford’s Medical Management NuSpin (somatropin) Injection J2941 PBM Nutropin and Nutropin AQ (somatropin) Injection J2941 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490, J3590, and J2182 Oxford’s Medical Management Coverage Criteria/Guidelines Precertification Guidelines: Infertility Diagnosis and Treatment N/A Precertification Guidelines: Respiratory Interleukins (IL) Policy Prior Authorization/Medical Necessity Guidelines: Nucynta ER Benefit Type Pharmacy/ Medical** Notes *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Medical N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Nuplazid Pharmacy N/A Precertification Guidelines: Formula & Specialized Food See Notes* *Benefit is State Specific. Medical Benefit/Pharmacy Benefit Prior Authorization/Medical Necessity Guidelines: NuSpin (somatropin) Prior Authorization/Medical Necessity Guidelines: Nutropin and Nutropin AQ (somatropin) Pharmacy N/A Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 83 of 147 Effective 06/01/2017 Medication/Drug Nuvaring (etonogestrel/ ethinyl estradiol) Nuvessa (metronidazole) Dosage Form CPT/HCPCS Code(s) Precertification Routing Vaginal Ring J7303 N/A Vaginal Gel J3490 Coverage Criteria/Guidelines Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Nuvigil (armodafinil) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Nuvigil (armodafinil) Tablet J8499 PBM Nymalize (nimodipine) Oral Solution J3490 N/A N/A Nystatin/triamcinol one (generic Mycolog II) cream Cream J3490 PBM Nystatin/triamcinol one (generic Mycolog II) ointment Ointment J3490 PBM Obredon solution (hydrocodone/ guaifenesin) Oral Solution J8499 PBM Ocaliva (obeticholic acid) Tablet J8499 PBM J3590 Oxford’s Medical Management Ocrevus (Ocrelizumab) Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Obredon Prior Authorization/Medical Necessity Guidelines: Ocaliva Precertification Guidelines: Ocrevus (Ocrelizumab) ©1996-2017, Oxford Health Plans, LLC Benefit Type Pharmacy* Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Page 84 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Octagam (immune globulin, Nonlyophilized) IV Infusion J1568 Oxford’s Medical Management Odefsey (emtricitabine / rilpivirine / tenofovir) Tablet J8499 N/A Odomzo (sonidegib) Capsule J8999 PBM Ofev (nintedanib) Capsule J8499 PBM Oforta (fludarabine phosphate) Oral J8562 N/A Tablet J8499 PBM Oleptro ER (trazodone hydrochloride ER) Tablet J8499 N/A olmesartan (generic Benicar) olmesartan/ hydrochlorothiazid e (generic Benicar HCT) N/A J8499 PBM Tablet J8499 PBM Olux (clobetasol propionate) Foam J3490 PBM Olux-CP (clobetasol propionate) Foam J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Tablet Prior Authorization/ Notification Guidelines: Odomzo Prior Authorization/Medical Necessity Guidelines: Ofev (nintedanib) N/A Oleptro (trazodone hydrochloride) Coverage Criteria/Guidelines Precertification Guidelines: o Immune Globulin (IVIG) and SCIG o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 85 of 147 Effective 06/01/2017 Medication/Drug Olux-E (clobetasol propionate) Dosage Form CPT/HCPCS Code(s) Precertification Routing Foam J3490 PBM Olysio (simeprevir) Capsules J8499 PBM Omeclamox-Pak (omeprazole, clarithromycin, amoxicillin) Tablet J8499 PBM Omeprazole (generic) Capsule J8499 N/A Omeprazole/ sodium bicarbonate (generic) Omnaris (ciclesonide) Capsule J8499 N/A J3490 Omnitrope (somatropin) Omtryg (omega-3acid ethyl esters A) Injection J2941 PBM Capsule J8499 PBM Onexton 1.23.75% (clindamycin phosphate and benzoyl peroxide) Gel J3490 PBM Onfi (clobazam) Oral J8999 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Onfi Pharmacy N/A N/A PBM Benefit Type Pharmacy N/A Nasal Spray Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: o Olysio - CT/NJ o Olysio - NY Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Omnitrope (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Omtryg ©1996-2017, Oxford Health Plans, LLC Page 86 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Onmel (itraconazole) Tablet J8499 PBM Onsolis (fentanyl buccal soluble film) Film J8499 N/A Onzetra Xsail (sumatriptan) Nasal Powder J3490 PBM Opana ER (oxymorphone extended release) Tablet J8499 PBM Opsumit (macitentan) Tablet J8499 PBM Optivar (brand only) (azelastine) Ophthalmic Drops N/A J3490 Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Opana ER Prior Authorization/Medical Necessity Guidelines: Opsumit Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass, Mixed Pollens Allergen Extract) Sublingual Tablet J8499 PBM Oramorph (morphine) Oral solution J8499 N/A N/A Pharmacy N/A Orbivan (butalbital, acetaminophen, and caffeine) Oral J8499 N/A N/A Pharmacy N/A Medical Hospital Outpatient Facility: Administration of Orencia in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Orencia (abatacept) Intravenous Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J0129 Oxford’s Medical Management Prior Authorization/Medical Necessity Guidelines: Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass Mixed Pollens Allergen Extract) Precertification Guidelines: o Orencia® (Abatacept) Injection for Intravenous Infusion o Specialty Medication Administration – Site of Care Review Guidelines ©1996-2017, Oxford Health Plans, LLC Page 87 of 147 Effective 06/01/2017 Medication/Drug Orencia (abatacept) Dosage Form CPT/HCPCS Code(s) Precertification Routing SQ Injection J3590 PBM Orenitram (treprostinil) Tablet J8499 PBM Orfadin (nitisinone) Capsule J8499 PBM Capsule J8499 PBM Orkambi™ (lumacaftor/ ivacaftor) Orkambi 100-125 mg tablet only (lumacaftor/ivacaft or) Ortho Cept (ethinyl estradiol and desogestrel) Ortho Cyclen (ethinyl estradiol and norgestimate) Coverage Criteria/Guidelines Tablet Pill Pill Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 S4993 S4993 N/A Pharmacy Pharmacy Notes Review Guidelines N/A N/A Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Orkambi Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. PBM N/A Prior Authorization/ Notification Guidelines: Orencia Step Therapy: Orencia Prior Authorization/Medical Necessity Guidelines: Orenitram Prior Authorization/ Notification Guideline: Orfadin Benefit Type Benefit Guidelines: Contraceptives Benefit Guidelines: Contraceptives ©1996-2017, Oxford Health Plans, LLC Page 88 of 147 Effective 06/01/2017 Medication/Drug Ortho Novum (ethinyl estradiol and norethindrone) Ortho-Evra (Generic) (Ethinyl estradiol and norelgestromin transdermal) Ortho-Evra (Brand Only) (Ethinyl estradiol and norelgestromin transdermal) Ortho TriCyclen/Lo (ethinyl estradiol and norgestimate) Dosage Form Pill Patch CPT/HCPCS Code(s) Precertification Routing S4993 N/A J7304 N/A Coverage Criteria/Guidelines Patch J7304 PBM Pill Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy S4993 N/A Benefit Guidelines: Contraceptives Benefit Guidelines: Contraceptives Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Pharmacy* Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Page 89 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Orthovisc (sodium hyaluronate) IntraArticular Injection J7324 Oxford’s Medical Management* Otezla (apremilast) Tablet J8499 PBM Otic Care (neomycin / polymyxin-B HC) Ophthalmic Drops J3490 N/A Otovel (ciprofloxacin and fluocinolone acetonide) Coverage Criteria/Guidelines J3490 Precertification Guidelines: Sodium Hyaluronate Medical Prior Authorization/Medical Necessity Guidelines: Otezla Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of N/A PBM Otrexup (methotrexate injection) Injection PBM Ovace Plus 9.8% lotion (sodium sulfacetamide) Lotion Ovace Plus foam (sodium sulfacetamide) Topical Foam Ovidrel (chorionic gonadotropin) J3490 Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM J3490 J0725* and J3490 PBM Precertification through Optum may be required* Notes *Precertification with review by a Medical Director or their Designee is required in all sites of service for J7321, J7324 and J7326. Otic solution Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Otrexup Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Infertility Diagnosis and Treatment ©1996-2017, Oxford Health Plans, LLC Page 90 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Ovrette (Norgestrel) Pill S4993 N/A Oxandrin (oxandrolone) Tablet J8499 N/A Coverage Criteria/Guidelines Tablet J8499 PBM Oxistat (oxiconazole nitrate) Cream J3490 PBM Oxistat (oxiconazole nitrate) Lotion J3490 PBM Oxtellar XR (oxcarbazepine extended release) Tablet J8499 PBM Oxycontin (oxycodone extended release) Tablet J8499 PBM Oxycodone ER 12HR Tablet Tablet J8499 PBM Oxymorphone extended release Tablets J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes coverage for coverage guidelines. Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Oxistat Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Oxteller XR Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Benefit Guidelines: Contraceptives N/A Oxaydo (oxycodone hcl) Benefit Type Prior Authorization/Medical Necessity Guidelines: Oxycontin Prior Authorization/Medical Necessity Guidelines: Oxycodone ER Prior Authorization/Medical Necessity Guidelines: Oxymorphone ©1996-2017, Oxford Health Plans, LLC Page 91 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Benefit Type Notes Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Oxytrol (oxybutynin) Tablets J8499 N/A N/A Ozurdex (dexamethasone) Intravitreal Implant J7312 N/A N/A Medical N/A Pacnex HP and Pacnex LP (benzoyl peroxide) Topical J3490 N/A N/A Pharmacy N/A Pancreaze (pancrelipase) Capsule J3490, PBM Pharmacy N/A Pantoprazole (generic) Tablet J8499 N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Tablet Pataday (olopatadine) Ophthalmic Solution Patanol (olopatadine HCL) Ophthalmic Solution Pazeo (olopatadine hydrochloride) Ophthalmic Solution J3490 PBM J3490 PBM J3490 PBM J3490 PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Step Therapy Guidelines: Pancreaze N/A Parlodel (bromocriptine mesylate) Pcp 100 Kit (magesium citrate, bisacodyl, petrolatum, polyethylene glycol 3350, metoclopramide) N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 92 of 147 Effective 06/01/2017 Medication/Drug Pediaderm AF (nystatin) and Pediaderm TA (triamcinolone) Dosage Form CPT/HCPCS Code(s) Precertification Routing Cream J3490 PBM Pediprox-4 (benzalkonium) Topical J3490 PBM Pegasys (peginterferon Alfa-2a) Injection J3490 PBM Peg-Intron (peginterferon Alfa-2b) Injection J3490 PBM Penicillin g potassium Penicillin g procaine, Aqueous Penlac Nail Lacquer (ciclopirox) (brand) IV Infusion J2510 Topical J3490 Oxford’s Medical Management* Prior Authorization/ Notification Guidelines: PEGIntron (peginterferon alfa-2b) Precertification Guidelines: Lyme Disease Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Drops Pennsaid 2% (diclofenac sodium) Topical Solution Percocet (acetaminophen and oxycodone) (brand only) Benefit Type J8499 PBM J3490 PBM Capsule J8499 PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM ©1996-2017, Oxford Health Plans, LLC Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical *Precertification Note: Precertification is only required only when used in the treatment of Lyme disease. Exception: Precertification is not required for CT Members. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A J2540 Pennsaid 1.5% Drops (diclofenac sodium) Pentasa (mesalamine) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Pegasys (peginterferon alfa-2a) Page 93 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Precertification through Optum may be required* Pergonal (menotropins) Injection S0122* and J3490 Pertzye (pancrelipase) Capsule J8499 PBM Pexeva (paroxetine mesylate) Tablet J8499 PBM Coverage Criteria/Guidelines Precertification Guidelines: Infertility Diagnosis and Treatment Step Therapy Guidelines: Pertzye Prior Authorization/Medical Necessity Guidelines: Select Brand Medications Oxford Benefit Type Pharmacy/ Medical** Notes *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Pharmacy N/A Phoslo (calcium acetate) Capsule J8499 N/A N/A Pharmacy* *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Planzapine, long acting Injection J2358 N/A N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Plegridy Pharmacy N/A Plavix (clopidogrel) (brand only) Tablet J8499 PBM Plegridy Pen & Prefilled Syringe (peginterferon beta-1a) Injection J3490 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 94 of 147 Effective 06/01/2017 Medication/Drug Plexion 9.8-4.8% cream, liquid, lotion (sulfacetamide/ sulfur) Plexion Cloth 9.8%-4.8% pads (sulfacetamide/ sulfur) Poly-Vi-Flor/Iron, Polyvitamin w/Fluoride, Tri-ViFlor/Iron, Trivitamin w/Fluoride, and ViDaylin Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Topical J3490 PBM Topical Tablet, Oral Solution J3490 J3490 PBM N/A Pomalyst (pomalidomide) Oral J8999 PBM* Potiga (Ezogabine) Tablets J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Type Notes Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for fluoride vitamins through their prescription drug plan. If the Member does not have fluoride vitamin coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. N/A Prior Authorization/ Notification Guidelines: Pomalyst Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Prior Authorization/ Notification Guidelines: Potiga (Ezogabine) Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 95 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Potaba (aminobenzoate potassium) Capsule, Tablet or Powder J8499 N/A Praluent (alirocumab) Injection J3490 PBM Pramosone E (hydrocortisone and pramoxine) Pregnyl (chorionic gonadotropin) Prescription Emollients / Mosturizers Prestalia (perindopril) Coverage Criteria/Guidelines N/A Topical Injection Topical J3490 J0725* and J3490 J3490 PBM* Precertification through Optum may be required* Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/Medical Necessity Guidelines: Praluent (alirocumab) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Infertility Diagnosis and Treatment Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tablet Pharmacy* PBM Benefit Type ©1996-2017, Oxford Health Plans, LLC Notes *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy/ Medical** *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. Pharmacy N/A Pharmacy N/A Page 96 of 147 Effective 06/01/2017 Medication/Drug Prevacid (lansoprazole) Solutab Lansoprazole generic Dosage Form Tablet CPT/HCPCS Code(s) Precertification Routing J8499 PBM Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Benefit Type Notes Pharmacy N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Prevacid (lansoprazole) Capsule Prevpac ((lansoprazole 30mg) (amoxicillin 500-mg) , (clarithromycin 500-mg) Capsules/ Tablets J8499 PBM* Prezcobix (darunavir/ cobicistat) Tablet J8499 N/A N/A Pharmacy N/A Prilosec (omeprazole) Capsule J8499 PBM N/A Pharmacy N/A Pharmacy N/A Prilosec Suspension (omeprazole) Pristiq (desvenlafaxine succinate) Privigen (immune globulin) J3490 N/A N/A Suspension Tablet IV Infusion Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J8499 J1459 PBM PBM Oxford’s Medical Management Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Pristiq* Pharmacy *Step Therapy coverage criteria is for groups on the Essential PDL only. More information about if this program applies can be found on myuhc.com or by calling customer service. Precertification Guidelines: o Immune Globulin (IVIG) and SCIG o Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Medical N/A ©1996-2017, Oxford Health Plans, LLC Page 97 of 147 Effective 06/01/2017 Medication/Drug ProAir Respimat (albuterol) Probuphine (buprenorphine) Procentra (dextroamphetamine) Prochieve (progesterone gel) Dosage Form Inhaler Subdermal implant Oral Solution Gel Procort (hydrocortisone acetate and pramoxine HCl) Topical Proctocort (hydrocortisone) (brand) Rectal cream Procysbi (cysteamine bitartrate) Capsule, Delayed Release Pellets Prodrin (acetaminophen/ caffeine/ isometheptene) CPT/HCPCS Code(s) Precertification Routing J3490 N/A J3490, J0570, and 11981 Oxford’s Medical Management J8499 PBM J3490 J3490 N/A Coverage Criteria/Guidelines N/A N/A Prior Authorization/ Notification Guidelines: Procentra Pharmacy N/A Pharmacy* Benefit Note for Infertility Use *Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Precertification Guidelines: Infertility Diagnosis and Treatment Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Procysbi (cysteamine bitartrate) Step Therapy: Procysbi PBM* PBM PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM* N/A Medical caplet Pharmacy Precertification Guidelines: Probuphine® (Buprenorphine) J8499 Notes J3490 Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 98 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Precertification through Optum may be required** Profasi (chorionic gonadotropin) Injection J0725* and J3490 Progesterone Injection J3490 N/A Prolensa (Bromfenac Ophthalmic) Opthalmic Solution J3490 PBM* Prolia, Xgeva (denosumab) Injection J0897 N/A Promacta (Eltrombopag) Tablet J8499 PBM Promiseb Complete Kit (Promiseb) Coverage Criteria/Guidelines J3490 Pharmacy/ Medical** Notes *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Medical N/A Pharmacy N/A N/A Medical N/A Pharmacy N/A Pharmacy N/A Topical Precertification Guidelines: Infertility Diagnosis and Treatment Benefit Type PBM Prior Authorization/ Notification Guidelines: Promacta Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Propecia, finasteride) Varies J3490 PBM N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Proscar (finasteride) Tablet J8499 and S0138 N/A N/A Pharmacy N/A Protein C [human] concentrate IV Infusion J2724 N/A N/A Medical N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 99 of 147 Effective 06/01/2017 Medication/Drug Protonix (Pantoprazole) (brand) Protonix Granules for Suspension (pantoprazole) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Oral J8499 PBM Protopic (tacrolimus) Topical Cream J8499 PBM Provigil (modafinil) (brand) Tablet J8499 PBM Provigil (modafinil) (generic) Tablet J8499 PBM Prozac (fluoxetine) (brand only) Tablets Prozena 4% patch (lidocaine) Pulmicort Flexhaler (budesonide) Topical patch Inhalation powder Pulmozyme® (Dornase Alfa) Inhalation Solution Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM J3490 N/A J3490 PBM 7639 PBM Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Protopic (tacrolimus) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Provigil (modafanil) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Provigil (modafanil) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Step Therapy Guidelines: Pulmicort Prior Authorization/ Notification Guidelines: Pulmozyme (dornase alfa) ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 100 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Puregon (follitropin beta) IM or SQ Injection S0128 Oxford’s Medical Management Purixan 20mg/ml (mercaptopurine) Oral Suspension J8499 PBM Qbrelis (lisinopril) Oral solution J8499 PBM Qnasl (beclomethasone dipropionate) Coverage Criteria/Guidelines Precertification Guidelines: Infertility Diagnosis and Treatment Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Prior Authorization/Medical Necessity Guidelines: Qbrelis Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Qudexy XR Nasal Spray J3490 PBM Quartette (ethinyl estradiol/ levonorgestrel) Tablet J8499 PBM Qudexy XR (topiramate) Capsule J8499 PBM Quillichew ER (methylphenidate hcl) extended release Chewable Tablet J8499 PBM Benefit Type See Notes* Notes *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit Medical Benefit for Members without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit.* *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Quillichew ER Pharmacy N/A Prior Authorization/ Notification Guidelines: Quillivant XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Quillivant XR (methylphenidate HCL) Liquid J8499 PBM Qutenza (capsaicin 8% patch) Patch J3490 N/A N/A Pharmacy N/A Rabeprazole (generic) Tablet J8499 N/A N/A Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 101 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Ragwitek (Short Ragweed Pollen Allergen Extract) Sublingual Tablet J8499 PBM Raloxifene (generic) Tablet J8499 PBM Rasuvo (methotrexate injection) AutoInjector J3490 PBM Ravicti (Glycerol Phenylbutyrate Oral Liquid) Oral Liquid J3490 PBM Rayaldee (calcifediol) Step Therapy Guidelines: Rasuvo Prior Authorization/ Notification Guidelines: Ravicti Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Rebetol (ribavirin) Prior Authorization/ Notification Guidelines: Rebif Step therapy: Rebif Medical Management Guidelines: Maximum Dosage Policy Capsule J8499 PBM Rayos (delayedrelease prednisone) Tablet J3490 PBM Rebetol (ribavirin) Tablet J3490 and J3590 N/A Rebif (interferon beta-1a) Injection, SQ Injection J1826, Q3025 and Q3026 PBM Reclast (zoledronic acid) IV Infusion J3489 N/A Rectiv (nitroglycerin ointment) Ointment J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Ragwitek (Short Ragweed Pollen Allergen Extract) Prior Authorization/ Notification Guidelines: Raloxifene N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Page 102 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Regranex (becaplermin gel) Gel S0157 PBM* Oxford’s Medical Management** Relenza (zanamivir) Oral Inhaler J3490 N/A Relistor (methylnatrexone bromide) Injection J3490 PBM Relistor (methylnaltrexone bromide) Relpax (eletriptan) Tablet Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J3490 Coverage Criteria/Guidelines N/A Pharmacy* Medical** Notes *Pharmacy Benefit: If dispensed by a retail pharmacy or Mail Order through PBM. Precertification through the PBM is required. **Medical Benefit: If provided in a hospital, MD's office, or in conjunction with Home Health Care. Precertification through Oxford’s Medical Management is required. Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Relistor Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. PBM PBM** Precertification Guidelines: Platelet Derived Growth Factors for Treatment of Wounds** Prior Authorization/ Notification Guidelines: Regranex (becaplermin) Benefit Type Supply Limit Guidelines: Triptans Supply Limits ©1996-2017, Oxford Health Plans, LLC Page 103 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Remicade (infliximab) Intravenous J1745 Oxford’s Medical Management* Renova (tretinoin) Varies S0117 PBM** Repatha (evolocumab) Injection J3490 PBM Repository Corticotropin Injection (H.P.Acthar Gel) Injection selfadministered Injection by a medical professional Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy PBM J3490 and J0800 Oxford’s Medical Management Precertification Guidelines: o Infliximab (Remicade and Inflectra) o Maximum Dosage Policy o Specialty Medication Administration – Site of Care Review Guidelines Benefit Type Medical Notes *Precertification Note: No precertification required in office. Precertification is required for outpatient and home setting. Hospital Outpatient Facility: Administration of Remicade in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines Prior Authorization/ Notification Guidelines: RetinA and Retin-A Micro (tretinoin) Pharmacy* **Precertification Note: Precertification is not required for Members under 30 years of age. *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Prior Authorization/Medical Necessity Guidelines: Repatha Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Acthar Pharmacy N/A Precertification Guidelines: Repository Corticotropin Injection (H.P. Acthar Gel) Medical N/A ©1996-2017, Oxford Health Plans, LLC Page 104 of 147 Effective 06/01/2017 Medication/Drug Repronex (menotropins) Dosage Form Injection Requip XL (ropinirole extended release) Tablet Rescula (unoprostone) Ophthalmologic Solution Restasis (cyclosporine ophthalmic emulsion) singleuse vials Restasis (cyclosporine ophthalmic emulsion) (multiuse) Retin-A (tretinoin) Ophthalmic Solution CPT/HCPCS Code(s) Precertification Routing S0122* and J3490 Precertification through Optum* J8499 and J3490 PBM J3490 PBM J3490 Coverage Criteria/Guidelines Precertification Guidelines: Human Menopausal Gonadotropins (hMG) Pharmacy/ Medical** Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Step Therapy Guidelines: Rescula Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Restasis (cyclosporine ophthalmic emulsion) Pharmacy N/A Pharmacy N/A Pharmacy N/A J3490 PBM Topical S0117 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. *Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of coverage for coverage guidelines. PBM Ophthalmic Solution Benefit Type Prior Authorization/Medical Necessity Guidelines: Restasis (cyclosporine ophthalmic emulsion)\ Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: RetinA and Retin-A Micro (tretinoin) ©1996-2017, Oxford Health Plans, LLC Page 105 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Retin-A Micro (tretinoin) Topical S0117 PBM Retin-A Micro Pump (tretinoin) (brand and generic) Topical S0117 PBM Revatio (sildenafil citrate) Tablet J3490 PBM Revatio (sildenafil citrate) 10mg/ml Revlimid (lenalidomide) Oral Suspension Oral J3490 J8999 PBM PBM Rexaphenac 1% cream (diclofenac) Cream J3490 PBM Rexulti (brexpiprazole) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: RetinA and Retin-A Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: RetinA and Retin-A Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Revatio (sildenafil citrate) Prior Authorization/Medical Necessity Guidelines: Revatio (sildenafil citrate) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Revlimid Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Step Therapy: Rexulti Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 106 of 147 Effective 06/01/2017 Medication/Drug Rhinocort Aqua (budesonide) Dosage Form CPT/HCPCS Code(s) Precertification Routing Nasal Spray J3490 PBM Rho(D) (immune globulin) BayRHoD, Gamulin Rh, HypRho-D MiniDose, MICRhoGAM, Mini-Gamulin Rh, RhoGAM, Rhophylac, WinRho SDF IV Infusion, IM Injection J2788, J2790, J2791, J2792, and 9038490386 N/A Rhofade (oxymetazoline hydrochloride) Topical Cream Riax (benzoyl peroxide) Topical Foam J3490 J3490 Tablets J8499 PBM Ribasphere (ribavirin) Capsule J3490, J3590 and J8499 N/A Tablet J8499 PBM Ritalin (methylphenidate) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Pharmacy N/A Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Risperdal (risperidone) (brand only) Notes Medical Management Guidelines: Intravenous Immunoglobulin (IVIg) and SCIG Ribapak (ribavirin) Benefit Type PBM N/A Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Ritalin ©1996-2017, Oxford Health Plans, LLC Page 107 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Ritalin LA (methylphenidate hydrochloride [extended release]) (brand and generic) Capsule J8499 PBM Ritalin SR (methylphenidate [controlledrelease]) Tablet J8499 PBM Rituxan (rituximab) Infusion J9310 Oxford’s Medical Management* Rizatriptan Tablet J8499 PBM** Rocaltrol (calcitriol) Capsule, Liquid S0169 N/A Rogaine (minoxidil) Rosadan kit (metronidazole) Varies J3490 and S0139 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Benefit Type Notes Pharmacy N/A Prior Authorization/ Notification Guidelines: Ritalin SR Pharmacy N/A eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines Precertification Guidelines: o Maximum Dosage Policy o Rituxan® (Rituximab) Medical *For Oncology and NonOncology Use: Precertification is required. Pharmacy* **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Pharmacy N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Pharmacy N/A Supply Limit Guidelines: Triptans Supply Limits N/A N/A Cream/Gel Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Ritalin LA Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 108 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Rosula (sodium sulfacetamide 10%/sulfur 4%) Topical Wash J3490 PBM Rosuvastatin (generic Crestor) Tablet J8499 N/A Rozerem (ramelteon) Tablet J8499 PBM Rubraca (rucaparib) J8999 PBM Tablets Ruconest (C1 esterase inhibitor [Recombinant]) Injection J0596 and J3490 PBM Rybix ODT (tramadol hydrochloride) Tablet J8499 N/A Rytary (carbidopa and levodopa) J8499 Tablets J8499 PBM Ryzolt (tramadol hydrochloride Extended release) Tablet J8499 N/A J8499 PBM Saizen (somatropin) Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J2941 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Tablet Step Therapy Guidelines: Rozerem (ramelteon) Prior Authorization/ Notification Guidelines: Rubraca Prior Authorization/ Notification Guidelines: Ruconest N/A PBM Ryvent (carbinoxamine maleate) Safyral (drospirenone/ ethinyl estradiol/ levomefolate) N/A Capsule Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Saizen (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 109 of 147 Effective 06/01/2017 Medication/Drug Sancuso (granisetron transdermal system) Dosage Form CPT/HCPCS Code(s) Precertification Routing Patch J3490 PBM Sanctura (trospium) (brand and generic) and Sanctura XR (trospium chloride) (brand and generic) Tablet J8499 PBM Sandostatin (octreotide acetate) SQ or IV Injection J2354 PBM Benefit Type Notes Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/ Notification Guidelines: Sandostatin Pharmacy N/A Medical *Precertification: Is required for services covered under the Member's general benefits package when performed in the office of a participating provider. Is not required, but encouraged for out of network services performed in the office that are covered under the Member's general benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered. Sandostatin LAR Depot (octreotide acetate) IM Injection J2353 Oxford’s Medical Management* Saphris (asenapine) Oral J8499 N/A N/A Pharmacy N/A Savaysa (edoxaban) Tablet J8499 N/A N/A Pharmacy N/A Savella (milnacipran) Tablet J8499 N/A N/A Pharmacy N/A Seebri Neohaler (glycopyrrolate) Inhalation powder J3490 N/A N/A Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Sandostatin, Sandostatin LAR DEPOT (octreotide acetate) ©1996-2017, Oxford Health Plans, LLC Page 110 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Selrx (selenium sulfide) Shampoo J3490 N/A Selzentry (Maraviroc) Tablet J8499 PBM Sensipar (cinacalcet) Tablet J8499 PBM Sernivo spray (betamethasone dipropionate) Topical Spray Seroquel (quetiapine fumarate) (brand only) Coverage Criteria/Guidelines N/A J3490 PBM Tablet J8499 PBM Seroquel XR (quetiapine) Tablet J8499 PBM Serostim (somatropin) Injection, SQ Injection J2941 PBM Signifor (pasireotide diaspartate) SQ Injection J3490 PBM Sildenafil citrate (generic Revatio) Tablet J8499 PBM Tablet Simbrinza 1-0.2% (Brimonidine and Brinzolamide) Opthalmic Suspension Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 Prior Authorization/Medical Necessity Guidelines: Serostim (somatropin) Prior Authorization/ Notification Guidelines: Signifor Prior Authorization/Medical Necessity Guidelines: Revatio (sildenafil citrate) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM J3490 PBM Prior Authorization/ Notification Guidelines: Selzentry Prior Authorization/Medical Necessity Guidelines: Sensipar Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Seroquel XR* Silenor (doxepin hydrochloride) N/A Benefit Type ©1996-2017, Oxford Health Plans, LLC Notes Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy *Step Therapy coverage criteria is for groups on the Essential PDL only. More information about if this program applies can be found on myuhc.com or by calling customer service. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 111 of 147 Effective 06/01/2017 Medication/Drug Simponi (golimumab) Simponi Aria (golimumab) Dosage Form SQ Injection Infusion Simvastatin (generic Zocor) 5mg, 10mg, 20mg, 40mg Tablets Singulair (montelukast sodium) (Brand only) Tablet, Granule CPT/HCPCS Code(s) J3490 J1602 J8499 Precertification Routing PBM Oxford’s Medical Management* Precertification Guidelines: Simponi Aria Prior Authorization/ Notification Guidelines: Cardiovascular Disease Prevention Zero Cost Share* PBM* J3490 PBM Singulair Chewable Tablet (montelukast Chewable Tablet sodium) (brand only) J3490 PBM Sirturo (bedaquiline) J8499 N/A Tablet Skelaxin (Brand only) (metaxalone) Skyla (LevonorgestrelReleasing Intrauterine Contraceptive System) 13.5mg Tablet J8499 PBM Oral Intrauterine Device Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8999 Q0090 PBM N/A Benefit Type Notes Pharmacy N/A Medical *Hospital Outpatient Facility: Administration of Simponi Aria in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Pharmacy *Applies to New York Lines of Business only Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. N/A Sitavig (acyclovir) Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Simponi (golimumab) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Guidelines: Contraceptives ©1996-2017, Oxford Health Plans, LLC Page 112 of 147 Effective 06/01/2017 Medication/Drug Sodium Sulfacetamide/ Sulfur 9%-4.5% Kit (generic Sumadan Kit) Dosage Form Toplical Lotion CPT/HCPCS Code(s) Precertification Routing J3490 PBM Solage (mequinol) Varies J3490 PBM Solaraze (diclofenac) Topical gel J3490 PBM Soliqua (insulin glargine/ lixisenatide) Soliris (eculizumab) Coverage Criteria/Guidelines N/A Injection Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 J1300 PBM Oxford’s Medical Management* Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Solaraze Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: o Soliris (eculizumab) o Specialty Medication Administration - Site of Care Review Guidelines ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Pharmacy N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Pharmacy N/A Pharmacy N/A Medical *Precertification Note: Precertification is not required for the drug itself [Soliris (eculizumab)], but precertification may be required for the site of care of the injection. When administered in: Provider’s Office or Freestanding Ambulatory Infusion Suite (not associated with a hospital): Administration of Soliris in a provider’s office or freestanding ambulatory infusion suite not associated with a hospital does not require precertification. Home: Administration of Soliris in the home requires precertification for the home care services (not for the Soliris itself). Refer to: Home Health Page 113 of 147 Effective 06/01/2017 Medication/Drug Solodyn (minocycline HCL) Dosage Form Tablet CPT/HCPCS Code(s) Precertification Routing J8499 N/A Coverage Criteria/Guidelines N/A Soltamox (tamoxifen citrate) Prior Authorization/ Notification Guidelines: Soltamox Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Care Hospital Outpatient Facility: Administration of Soliris in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration - Site of Care Review Guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Oral Solution J8999 Soma 250mg (carisoprodol) / carisoprodol 250mg (generic) Tablet J3490, J8499 PBM Somac, Pantoloc, Protium, Pantecta, and Pantoheal (Pantoprazole) Tablet J8499 N/A N/A Pharmacy N/A Somatuline Depot (lanreotide) IM Injection J1930 N/A N/A Medical N/A Somavert (pegvisomant) Injection, SQ Injection J3590 PBM Pharmacy N/A Sonata (zaleplon) Tablet J8499 N/A Pharmacy N/A Soolantra (ivermectin) Cream J3490 PBM Pharmacy N/A Pharmacy N/A Sorilux (calcipotriene) PBM N/A Topical Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Prior Authorization/Medical Necessity Guidelines: Somavert Step Therapy Guidelines: Soolantra Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 114 of 147 Effective 06/01/2017 Medication/Drug Sotylize (sotalol hydrochloride) Dosage Form Oral Solution CPT/HCPCS Code(s) J8499 Precertification Routing PBM Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Benefit Type Notes Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: o Sovaldi - CT/NJ o Sovaldi - NY Pharmacy N/A Precertification Guidelines: Spinraza (Nusinersen) Medical N/A Sovaldi (sofosbuvir) Tablet J8499 PBM Spinraza (Nusinersen) Intrathecal injection J3490 Oxford’s Medical Management Spiriva Respimat (tiotropium) Inhaler J3490 N/A N/A Pharmacy N/A Sporanox (itraconazole) Capsule J1835 N/A N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Spritam (levetiracetam) Tablets J8499 PBM Sprix Nasal Spray (ketorolac tromethamine) Nasal Spray J3490 N/A Sprycel (dasatinib) SSS 10-4 (sodium polystyrene sulfonate) Oral Cream Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8999 J3490 PBM* PBM Prior Authorization/Medical Necessity Guidelines: Spritam Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Prior Authorization/Medical Necessity Guidelines: Sprycel Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 115 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Staxyn (vardenafil) Oral Stelara (ustekinumab) Subcutaneo us Injection Stelara (ustekinumab) Stendra (avanafil) J3490 PBM J3357 PBM* Intravenous Infusion J3590 Oxford’s Medical Management Tablet J3490 PBM Stiolto Respimat (olodaterol / tiotropium) Inhaler J3490 PBM Stivarga (regorafenib) Tablet J8999 PBM Strattera (atomoxetine) Capsule J8499 N/A Strensiq (asfotase alfa) Injection J3490 PBM Striant (testosterone) Tablet J8499 PBM Stribild® (elvitegravir/ cobicistat/ emtricitabine/ tenofovir disoproxil fumarate) Tablet J8499 PBM Striverdi Respimat (olodaterol) Inhalation Spray J3490 N/A Suboxone (buprenorphine/ naloxone) Sublingual Film, Tablets Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy N/A PBM Benefit Type Notes Pharmacy N/A Pharmacy *Precertification through PBM if obtained at a pharmacy. No precertification if provided in an office or outpatient setting. Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Strensiq Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Striant Pharmacy N/A Step Therapy Guidelines: Stribild Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A J3490 Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Stelara Injection for Subcutaneous Use Precertification Guidelines: o Maximum Dosage Policy o Stelara (Ustekinumab) Injection for Intravenous Use Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Stivarga Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products ©1996-2017, Oxford Health Plans, LLC Page 116 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Subsys (fentanyl sublingual spray) Oral Spray J3490 PBM* Succimer (DMSA), (dimercaptosuccini c acid) Oral Agent J3490 N/A* N/A Sumadan (sodium sulfacetamide and sulfur) Topical Kit Sumadan Cleanser (sodium sulfacetamide and sulfur) in a Moisturizing Novasome® Vehicle) (brand only) Topical Wash Sumadan XLT Kit (sulfacetamide sodium, sulfur, avobenzone, octinoxate, and octisalate) Sumatriptan J3490 PBM J3490 PBM Topical Tablet, Nasal Spray, Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 J3490, J8499, and J3030 PBM PBM** Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Subsys Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy* New Jersey Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy *Oral chelation agents do not require precertification. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Supply Limit Guidelines: Triptans Supply Limits ©1996-2017, Oxford Health Plans, LLC Page 117 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Sumavel Dosepro (Sumatriptan) Injection Sumaxin TS and Sumaxin CP (sodium sulfacetamide and sulfur) Topical Supartz (sodium hyaluronate) IntraArticular Injection J3490 and J8499 PBM** J3490 PBM J7321 Oxford’s Medical Management* Coverage Criteria/Guidelines Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Sodium Hyaluronate Benefit Type Notes Pharmacy* Pharmacy N/A Medical *Precertification with review by a Medical Director or their Designee is required in all sites of service for J7321, J7324 and J7326. Medical *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Supprelin LA (histrelin acetate implant) SC Implant J9226 Oxford’s Medical Management* Suprax Chewable Tablets (cefixime) Tablet J3490 N/A N/A Pharmacy N/A Sustenna (paliperidone palmitate extended release) Extended Release Injection J2426 N/A N/A Medical N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and Sutent (sunitinib) Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy PBM* Precertification Guidelines: Gonadotropin Releasing Hormone Analogs Prior Authorization/ Notification Guidelines: Sutent ©1996-2017, Oxford Health Plans, LLC Page 118 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Sylatron (peginterferon alfa-2b) Injection J3490 PBM Symbicort (budesonide/ formoterol fumarate dehydrate) Aerosol J3490 N/A Synagis (palivizumab) Injection J3490 Oxford’s Medical Management Synalar 0.01% solution (fluocinolone acetonide) (brand) Topical solution Synalar 0.025% cream/ ointment (fluocinolone acetonide) (brand) Topical cream / ointment Synalar Kit (fluocinolone acetonide) J3490 Coverage Criteria/Guidelines N/A J3490 Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical *Precertification is not required in the office for Oxford's preferred products of Euflexxa, Synvisc or Synvisc-One (J7323 and J7325). Pharmacy N/A Pharmacy N/A PBM Synarel (nafarelin acetate) Nasal Spray J3490 N/A Synvisc and Synvisc-One (Hylan G-F-20) IntraArticular Injection J7325 Oxford’s Medical Management* Synjardy (empagliflozin/ metformin hydrochloride) Tablet J8499 PBM Syprine (trientine hydrochloride) Oral Agent J3490 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy N/A PBM J3490 Pharmacy N/A PBM Topical N/A Medical PBM Synalar TS (fluocinolone acetonide) Pharmacy Precertification Guidelines: Synagis (palivizumab) Topical Notes quantity limit guidelines. J3490 Prior Authorization/ Notification Guidelines: Sylatron Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Precertification Guidelines: Sodium Hyaluronate Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Syprine ©1996-2017, Oxford Health Plans, LLC Page 119 of 147 Effective 06/01/2017 Medication/Drug Taclonex Ointment (Brand Only) (calcipotriene/ betamethasone dipropionate) Dosage Form CPT/HCPCS Code(s) Precertification Routing Ointment J3490 PBM Tafinlar (dabrafenib) Capsule J8499 PBM Tagrisso (osimertinib) Tablet J8999 PBM Taltz (ixekizumab) Injection J3490 PBM Tamiflu (oseltamivir phosphate) Capsule, Powder or Oral Suspension J3490 and J8499 N/A Tamoxifen Oral J8999 PBM Tarceva (erlotinib) Coverage Criteria/Guidelines Oral J8999 PBM Targadox (doxycycline) Tablet J8499 PBM Targretin Gel (bexarotene) Topical Gel J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Tafinlar Prior Authorization/ Notification Guidelines: Tagrisso Prior Notification/Medical Necessity Guidelines: Taltz N/A Prior Authorization/ Notification Guidelines: Tamoxifen Benefit Type Pharmacy Pharmacy Notes N/A N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Prior Authorization/ Notification Guidelines: Tarceva Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A N/A ©1996-2017, Oxford Health Plans, LLC Page 120 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Tasigna (nilotinib) Oral J8999 PBM* Tasmar (tolcapone) (brand) Taytulla (norethindrone acetate and ethinyl estradiol, and ferrous fumarate) Tablet J8499 PBM Tablet J8499 PBM Tazorac (taxarotene) Varies J3490 PBM** Tecfidera (dimethyl fumarate) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Benefit Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Prior Authorization/ Notification Guidelines: Tasigna Step Therapy Guidelines: Tasigna Pharmacy** Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Benefit Guidelines: Contraceptives Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Tazorac (taxarotene) Pharmacy* **Precertification Note: Precertification is not required for Members under 30 years of age. Precertification for NJ Small LOBs is based on the Member's benefit. *Benefit Note: Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Prior Authorization/ Notification Guidelines: Tecfidera (dimethyl fumarate) Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 121 of 147 Effective 06/01/2017 Medication/Drug Technivie (ombitasvir/ paritaprevir/ ritonavir) Teflaro (ceftaroline fosamil) Tekamlo (aliskiren/ amlodipine) Temodar (temozolomide) Tenoretic (atenolol/ chlorthalidone) (brand) Tenormin (atenolol) (brand) Terbinex (terbinafine hydrochloride) Test Strips and Meters (Diabetic): • Abbott Diabetic Test Strips and Meters • Bayer Diabetic Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Injection J0712 N/A N/A Tablet Oral Tablet J8499 J8999 J8499 PBM PBM* J8499 Prior Authorization/ Notification Guidelines: Temodar Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM PBM Tablet J8499 PBM A4253 – Test strips Test Strips Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy PBM E0607 Meter Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tablet Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: o Technivie - CT/NJ o Technivie - NY Prior Authorization/ Notification Guidelines: O Test Strips O Diabetic Test Strips (NJ) ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy *The Test Strips Oxford policy applies to New York and Connecticut plans and products only. Page 122 of 147 Effective 06/01/2017 Medication/Drug Test Strips and Meters • Roche Diabetic Test Strips and Meters Dosage Form CPT/HCPCS Code(s) Precertification Routing Testim (testosterone gel) Gel J3490 PBM Testosterone cypionate and estradiol cypionate Injection J3490 N/A Testosterone enanthate and estradiol valerate Injection J3490 Testosterone powder Powder J3490 Coverage Criteria/Guidelines Topical J3490 N/A N/A Medical N/A N/A N/A Medical N/A PBM N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A PBM Testosterone topical gel (generic Vogelxo) Topical J3490 PBM Testosterone topical gel (manufacturer of Perrigo Israel) Topical Gel J3490 PBM Testred (methyltestosterone) Capsule J3490 N/A N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes Pharmacy Testosterone topical gel (generic Testim) Prior Authorization/Medical Necessity Guidelines: Testim Benefit Type Prior Authorization/Medical Necessity Guidelines: Topical Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Topical Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Topical Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 123 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Thalomid (thalidomide) Oral J8999 PBM* Thyrogen (thyrotropin alfa) Injection J3490 N/A Tirosint (levothyroxine sodium) Capsule J8499 PBM Capsule TNKase (tenecteplase) Intravenous Tobi™ Nebulizer Solution (Tobramycin Inhalation Solution) and Tobi® Podhaler™ (Tobramycin Inhalation Powder) Inhalation Powder or Inhalation Solution J8499 PBM J3490 and J3101 N/A PBM Ointment Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Benefit Type Pharmacy** Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Medical N/A Pharmacy N/A Pharmacy N/A Medical N/A Prior Authorization/ Notification Guidelines: TOBI Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A J3490 Prior Authorization/ Notification Guidelines: Thalomid N/A Tivorbex (indomethacin) Tobradex ST (tobramycindexamethasone) Coverage Criteria/Guidelines ©1996-2017, Oxford Health Plans, LLC Page 124 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Tobramycin nebulized solution (generic Tobi) Inhalation Solution Tolak 4% cream (fluorouracil) Topical Cream J3490 PBM J3490 PBM Tolterodine (generic Detrol) Tablets J8499 PBM Topamax (topiramate) Tablet or Capsule J8499 PBM Topicort Spray (Desoximetasone) Topical spray J3490 PBM Toujeo Solostar (insulin glargine) Injection J3490 PBM Tracleer (bosentan) Tablet J3490 PBM Tramadol extended-release (generic ryzolt) Tablet/ Capsule J8499 Tramadol extendedrelease (generic ryzolt) Travoprost (generic Travatan) Ophthalmic Solution J3490 PBM Trelstar Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3315 Oxford’s Medical Management* Coverage Criteria/Guidelines Prior Authorization/ Notification Guidelines: Tobramycin nebulized solution Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Topamax Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Tracleer (bosentan) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Travoprost (generic Travatan) Precertification Guidelines: Gonadotropin Releasing Hormone Analogs ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Page 125 of 147 Effective 06/01/2017 Medication/Drug Tresiba Flex Touch (insulin degludec) Dosage Form Injection CPT/HCPCS Code(s) J3490 Precertification Routing PBM Tretin-X 0.075% cream (tretinoin) 0.075% Cream S0117 and J3490 PBM Tretin-X 0.0375% cream (tretinoin) 0.0375% Cream J3490 PBM Tretin-X Kit (tretinoin) Topical J3490 PBM Treximet (sumatriptan naproxen) Tablet J8499 PBM Trezix (acetaminophen/ caffeine/ dihydrocodeine) Capsule J8499 PBM Triamcinolone acetonide Injection J3300 N/A Trianex (triamcinolone) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Supply Limit Guidelines: Triptans Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Ointment Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Tresiba Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Page 126 of 147 Effective 06/01/2017 Dosage Medication/Drug Form Tribenzor (amlodipine, olmesartan, Tablet medoxomil, hydrochlorothiazide) Tricor/Fenofibrate 48mg and 145mg (generic Tricor) (fenofibrate) and Trilipix (fenofibrate acid) Triglide (fenofibrate) CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines J8499 PBM Tablet J8499 PBM Tablet J8499 PBM Tri-Luma (hydroquinone) Varies J3490 N/A Trileptal (oxcarbazepine) Tablet J8499 PBM Trilipix (fenofibrate acid) Capsule J8499 PBM Trintellix (vortioxetine) Tablet J8499 PBM Triphasil (levonorgestrel and ethinyl estradiol) Pills S4993 N/A Trisenox (arsenic trioxide) Injection J9017 N/A* Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Notes Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Benefit Type Prior Authorization/Medical Necessity Guidelines: Trileptal Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guideline: Trintellix Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Medical Management Guidelines: Injectable Chemotherapy Drugs: Medical *Precertification is not required for intravenous chemotherapy drugs however, Oxford will ©1996-2017, Oxford Health Plans, LLC Page 127 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Triumeq (dolutegravir/ abacavir/ lamivudine) Tablet J8499 N/A Trokendi XR (topiramate) Capsule J8499 PBM Tablet J8499 PBM Trulicity (dulaglutide) Injection J3490 N/A Truvada (emtricitabine and tenofovir disoproxil fumarate) Tablet Tuzistra XR (codeine/ chlorpheniramine) Oral suspension Tykerb (lapatinib) N/A Trulance (plecanatide) Twynsta (Telmisartan, amlodipine) Coverage Criteria/Guidelines Application of NCCN Clinical Practice Guidelines J8499 N/A N/A N/A J8499 PBM Tablet Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J8999 PBM PBM* Prior Authorization/Medical Necessity Guidelines: Trokendi XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Tykerb ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes provide a pre-service clinical review and coverage determination upon request. In the absence of precertification, Oxford will perform a postservice retrospective review upon claim submission for patients 19 years of age or older. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy* New Jersey Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Pharmacy N/A Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Page 128 of 147 Effective 06/01/2017 Dosage Form CPT/HCPCS Code(s) Precertification Routing Tysabri (natalizumab) Intravenous J2323 N/A Tyvaso (treprostinil) Inhalation Solution J7686 PBM Uceris (budesonide) Tablet J8499 N/A Uceris foam Topical J3490 N/A Uloric (febuxostat) Tablet J8499 PBM Medication/Drug Ultrasal-ER 28.5% topical solution (salicylic acid) Topical Solution J8499 N/A Ultravate X Combination Package (halobetasol) Topical J3490 PBM Ultresa (pancrelipase) Capsule J8499 PBM Umecta emulsion, foam, suspension (urea) Foam/ Suspension Umecta Kit (nail film pen/film suspension) (urea nail film and hyaluronic acid) Nail Film Pen/Film suspension Umecta PD (urea) Topical Suspension Coverage Criteria/Guidelines N/A N/A Pharmacy N/A N/A Pharmacy N/A N/A Step Therapy Guidelines: Uloric Pharmacy N/A Pharmacy N/A Pharmacy Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy N/A Pharmacy N/A Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy PBM PBM J3490 PBM Prior Authorization/Medical Necessity Guidelines: Tyvaso (treprostinil) N/A J3490 Notes Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Medical J3490 Benefit Type Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Step Therapy Guidelines: Ultresa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 129 of 147 Effective 06/01/2017 Medication/Drug Uptravi (selexipag) Uramaxin GT 45% (urea in ammonium lactate) Dosage Form Tablet CPT/HCPCS Code(s) J8499 Precertification Routing PBM Foam J3490 PBM Uramaxin GT Kit urea plus moisturizer) Cream Urevaz 44% cream (urea) Topical cream J3490 PBM Utibron Neohaler (indacaterol/ glycopyrrolate) Inhalation powder J3490 N/A J3490 PBM N/A Utopic (urea) 41% Topical J3490 PBM Valchlor Gel (mechlorethamine) Topical J3490 PBM Valcyte (valganciclovir) (brand) Tablet J8499 PBM Valium (diazepam) (brand only) Tablet J8499 PBM Valsartan (generic Diovan) Capsule J8499 N/A Tablet J8499 PBM Valturna 150160mg, 300mg 320mg (aliskiren and valsartan) Tablet J8499 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Valchlor Gel Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Valtrex (valacyclovir) (brand only) Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Uptravi Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 130 of 147 Effective 06/01/2017 Medication/Drug Vanatol LQ (butalbital/ acetaminophen/ caffeine Vaniqa (eflornithine) Vanos (fluocinonide) Dosage Form Oral Solution Varies CPT/HCPCS Code(s) Precertification Routing J8499 PBM J3490 PBM Coverage Criteria/Guidelines N/A Topical J3490 PBM Vantas (histrelin implant) SC Implant J9225 Oxford’s Medical Management* Varubi (rolapitant) Tablet J8670 N/A Vascepa (omega3-acid ethyl esters) Capsule J3490 PBM Vascepa 0.5 gram only (omega-3acid ethyl esters) Capsule J3490 PBM Vaseretic (enalapril/ hydrochlorothiazide) Tablet (brand) PBM Vasotec (enalapril) (brand Tablet J8499 PBM Vecamyl (mecamylamine) Tablet J8499 PBM Vectical (calcitriol) Topical J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Guidelines: Gonadotropin Releasing Hormone Analogs N/A Prior Authorization/ Notification Guidelines: Vascepa J8499 Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms Prior Authorization/ Notification Guidelines: Vascepa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Vecamyl (mecamylamine) N/A ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Pharmacy N/A Medical *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 131 of 147 Effective 06/01/2017 Medication/Drug Velphoro (sucroferric oxyhydroxide) Veltassa (patiromer) Veltin (clindamycin phosphate and tretinoin) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 N/A Oral Suspension J8499 PBM Coverage Criteria/Guidelines N/A Gel J3490 PBM Vemlidy (tenofovir alafenamide) Tablet J8499 PBM Venclexta (venetoclax) Tablet J8999 PBM Venlafaxine ER (venlafaxine hydrochloride extended release) Ventavis (iloprost) Veramyst (fluticasone furoate) Tablet Inhalation Solution Nasal Spray J8499 Q4074 J3490 PBM PBM* Prior Authorization/Medical Necessity Guidelines: Ventavis (iloprost) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Vermox Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications PBM Verdeso (desonide) Topical J3490 PBM Vermox (mebendazole) Oral Suspension J8499 PBM Versacloz (clozapine) Oral suspension Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Prior Authorization/Medical Necessity Guidelines: Veltassa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Venclexta Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy and DME (Medical) *The I-neb AAD System (K0730) for administration of Ventavis® (iloprost) requires precertification through Oxford's Medical Management Department and coverage is provide under the Medical benefit. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 132 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Vesicare (solifenacin) Tablet J8499 PBM Viagra (sildenafil citrate) Tablet J3490 PBM Vibativ (telavancin) Injection J3095 N/A Viberzi (eluxadoline) Tablet J8499 PBM Vicodin 5/300mg (hydrocodone and acetaminophen) Vicodin ES 7.5/300mg (hydrocodone and acetaminophen) N/A Tablet J8499 PBM Tablet J8499 PBM Vicodin HP 10/300mg (hydrocodone and acetaminophen) Tablet J8499 PBM Victrelis (boceprevir) Tablet J8499 PBM Viekira Pak Viekira XR (ombitasvir, paritaprevir (ABT450) and ritonavir) Oral Vimovo (naproxen sodium plus proton pump inhibitor) Tablet Vimpat (Lacosamide) Injection Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Erectile Dysfunction Agents PBM Prior Authorization/Medical Necessity Guidelines: Viberzi Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Victrelis Prior Authorization/Medical Necessity Guidelines: o Viekira Pak - CT/NJ o Viekira Pak - NY Benefit Type Notes Pharmacy N/A Pharmacy N/A Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A J3490 N/A N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. C9254 and J3490 N/A N/A Medical N/A ©1996-2017, Oxford Health Plans, LLC Page 133 of 147 Effective 06/01/2017 Medication/Drug Viokace (pancrelipase) Viramune (nevirapine) Viramune XR 400mg (Brand Only) (nevirapine) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Tablet J3490 PBM Tablet J8499 PBM Tablet J8499 PBM* Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Vimpat (Lacosamide) Step Therapy Guidelines: Viokace Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Virasal (salicylic acid) (brand only) Topical J3490 N/A N/A Pharmacy Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Visudyne (verteporfin) Infusion J3396 N/A N/A Medical N/A Vitamin B-12 Injection J3420 N/A N/A Medical N/A Vitekta (elvitegravir) Tablet J8499 N/A N/A Pharmacy N/A VitrasertGanciclovir Vitreal Implant Eye Implant J3490 N/A N/A Medical N/A Vituz (hydrocodone bitartrate, and chlorpheniramine maleate) Oral Solution J8499 PBM Pharmacy N/A Vivitrol (Naltrexone) Injection J2315 N/A Medical N/A Pharmacy N/A Vivlodex (meloxicam) N/A Capsule Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 134 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Vogelxo (testosterone) Votrient (pazopanib) Topical Oral J3490 J8999 PBM PBM* VPRIV (velaglucerase) Injection J3385 N/A Vraylar (cariprazine) Capsules J8499 N/A Vusion (miconazole/ zinc oxide) J3490 J3490 PBM Vyvanse (lisdexamfetamine) Tablet J3490 N/A Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Pharmacy N/A Prior Authorization/ Notification Guidelines: Votrient Pharmacy** Medical Management Guidelines: Enzyme Replacement Therapy (ERT) for Gaucher Disease Medical N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Topical Notes PBM Vytone (hydrocortisone/ lodoquinol) Benefit Type Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Ointment Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Vogelxo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Vyvanse (lisdexamfetamine) ©1996-2017, Oxford Health Plans, LLC Page 135 of 147 Effective 06/01/2017 Medication/Drug Weight Loss: Adipex-P , diethylpropion, benzphetamine, Belviq, Belviq XR, Contrave, phendimetrazine, phentermine, Qsymia, Saxenda, Xenical Wellbutrin (bupropion) (brand) Wellbutrin SR (brand only) (bupropion) Dosage Form Tablet or Capsule Tablet CPT/HCPCS Code(s) Precertification Routing J8499 PBM J8499 J8499 Pharmacy* Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and PBM Tablet J8499 PBM Winstrol (stanozolol) Tablet J8499 N/A Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8999 PBM* Notes *Coverage is limited to Members with coverage for weight loss medications through their prescription drug plan. If the Member does not have weight loss medication coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage, or Prescription Drug Rider, language for coverage guidelines. ** Prior Authorization Guidelines only apply to New York plans and products Prior Authorization/Medical Necessity Guidelines: Weight Loss Tablet Benefit Type PBM Wellbutrin XL (bupropion extended release) Xalkori (crizotinib) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Prior Authorization/ Notification Guidelines: Xalkori ©1996-2017, Oxford Health Plans, LLC Page 136 of 147 Effective 06/01/2017 Medication/Drug Xanax (alprazolam) (brand only) Xanax XR (alprazolam) (brand only) Dosage Form CPT/HCPCS Code(s) Precertification Routing Tablet J8499 PBM Tablet J8499 PBM Xartemis XR 7.5/325mg (oxycodone hydrochloride and acetaminophen) Capsule J8499 PBM Xeljanz (tofacitinib) Tablet J8499 PBM Xeljanz XR Tablets J8499 PBM Xenazine (tetrabenazine) (brand) Coverage Criteria/Guidelines Tablet Xeomin (incobotulinumtoxin SQ Injection A) J8499 PBM J0588 Oxford’s Medical Management Xerese (acyclovir or hydrocortisone) Cream J3490 PBM Xiaflex (collagenase clostridium histolyticum) Injection J0775 N/A Xifaxan (rifaximin) Tablet J8499 PBM Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Xeljanz Prior Authorization/Medical Necessity Guidelines: Xeljanz XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes quantity limit guidelines. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Precertification Guidelines: Botulinum Toxins A and B Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Medical N/A Pharmacy N/A N/A Prior Authorization/Medical Necessity Guidelines: Xifaxan ©1996-2017, Oxford Health Plans, LLC Page 137 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines Xigduo XR (Dapagliflozin and Metformin HCl) Tablet Xiidra (lifitegrast) Ophthalmic solution Xodol 10/300 (hydrocodone/ acetaminophen)(br and and generic) Xodol 5/300 (hydrocodone / acetaminophen) (brand and generic) J3490 Tablet J8499 Prior Authorization/Medical Necessity Guidelines: Xiidra Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Precertification Guidelines: Xolair (omalizumab) Medical N/A Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Prior Authorization/Medical Necessity Guidelines: Xtampza ER Pharmacy N/A Prior Authorization/ Notification Guidelines: Xtandi Step Therapy Guidelines: Xtandi Pharmacy N/A PBM* Tablet J8499 PBM* Xodol 7.5/300 (hydrocodone / acetaminophen) (brand and generic) Tablet J8499 PBM* Xolair (omalizumab) SQ Injection J2357 Oxford’s Medical Management Xopenex Nebules (levalbuterol hydrochloride) Generic Xopenex nebules Inhalation Solution J3490 PBM Xtampza ER (oxycodone) Capsule J8499 PBM Xtandi (enzalutamide) Pharmacy PBM* PBM Capsule Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8999 PBM Notes The Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) policy applies to New York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Prior Authorization/ Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) J3490 Benefit Type ©1996-2017, Oxford Health Plans, LLC Page 138 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Xultophy (insulin degludec and liraglutide) Injection J3490 PBM Xuriden (uridine triacetate) Oral granules J8499 PBM Xyrem (Sodium Oxybate) Oral Solution J8499 PBM Yasmin 28 (drospirenoneethinyl estradiol) Pill S4993 N/A Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Xuriden Prior Authorization/Medical Necessity Guidelines: Xyrem (sodium oxybate) Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their certificate of coverage or Prescription Drug Rider language for coverage guidelines. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Yosprala (aspirin/ omeprazole) Tablet J8499 PBM Zarxio (filgrastimsndz) Injection J3490 N/A N/A Pharmacy N/A Zavesca® (miglustat) Capsule J8499 N/A N/A Pharmacy N/A Zecuity 6.5mg/4 hr patch (sumatriptan iontophoretic) Transdermal patch Pharmacy N/A Not covered Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to member specific benefit plan document as applicable. Pharmacy N/A Zegerid (omeprazole/ sodium bicarbonate) Capsule Zegerid suspension Oral (omeprazole/ suspension sodium bicarbonate) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J3490 PBM J8499 N/A J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Prior Authorization/Medical Necessity Guidelines: NonSolid Oral Dosage Forms ©1996-2017, Oxford Health Plans, LLC Page 139 of 147 Effective 06/01/2017 Medication/Drug Zelboraf (vemurafenib) Dosage Form Oral CPT/HCPCS Code(s) Precertification Routing J8999 PBM* Zembrace SymTouch (sumatriptan succinate) Injection J3490 PBM Zemplar (paricalcitol) Injection J2501 N/A Zenatane Capsule J8499 PBM Coverage Criteria/Guidelines Zepatier (elbasvir/ grazoprevir) Tablet Prior Authorization/ Notification Guidelines: Zelboraf Pharmacy** Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A PBM Tablet Zestoretic (lisinopril/ Tablet hydrochlorothiazide) (brand) Zestril (lisinopril) (brand) J8499 J8499 PBM J8499 PBM Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. Zenzedi (dextroamphetami ne sulfate) Benefit Type Prior Authorization/ Notification Guidelines: Zenatane Prior Authorization/ Notification Guidelines: Zenzedi Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New And Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: o Zepatier - CT/NJ o Zepatier - NY Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Page 140 of 147 Effective 06/01/2017 Medication/Drug Zetonna (ciclesonide) Zevalin (ibritumomab tiuxetan) Dosage Form Inhalation Solution Injection Powder Packet CPT/HCPCS Code(s) Precertification Routing J8499 N/A N/A Pharmacy N/A A9542 and A9543 N/A N/A Medical N/A J3490 N/A N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Ziana (clindamycin phosphate and Tretinoin Gel J3490 PBM Zinbryta (daclizumab) Injection J7513 PBM Zioptan (tafluprost) Opthalmic Solution J8499 PBM Zipsor 25mg (diclofenac pottassium) Capsule Zithromax (azithromycin) Zofran (ondansetron hydrochloride) Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Zinbryta Step Therapy Guidelines: Zioptan (tafluprost) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes J8499 PBM Capsule, Oral Solution or Tablet J3490 and J8499 N/A N/A Pharmacy N/A Oral Solution Q0179 and S0181 N/A N/A Pharmacy N/A IV Injection J2405 N/A N/A Medical N/A Zofran and Zofran ODT (ondansetron) Tablet J8499 N/A N/A Pharmacy N/A Zohydro ER (hydrocodone bitartrate extended release) Tablet J8499 PBM Pharmacy N/A Medical *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Zoladex SC Implant Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J9202 Oxford’s Medical Management* Prior Authorization/Medical Necessity Guidelines: Zohydro ER Precertification Guidelines: Gonadotropin Releasing Hormone Analogs ©1996-2017, Oxford Health Plans, LLC Page 141 of 147 Effective 06/01/2017 Medication/Drug Zoledronic acid Dosage Form Injection CPT/HCPCS Code(s) J3489 Precertification Routing N/A Zoloft (sertraline) (brand only) Tablet J8499 PBM Zolpidem extended release (zolpidem) Tablet J8499 N/A Zolpimist (zolpidem tartrate) Oral Spray J8499 PBM Zolvit (hydrocodone bitartrate and acetaminophen) Liquid J8499 N/A Zomacton (somatropin) Injection J2941 PBM Zometa (zoledronic acid) Injection J3489 N/A Zomig and ZomigZMT (zolmitriptan) Zonacort (dexamethasone) Tablet and Nasal Spray Tablet Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 and J3590 J8499 PBM** PBM Coverage Criteria/Guidelines Medical Management Guidelines: Maximum Dosage Policy Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Notes Medical N/A Pharmacy N/A N/A Pharmacy N/A Step Therapy Guidelines: Zolpimist (zolpidem tartrate) Pharmacy N/A N/A Pharmacy N/A Pharmacy N/A Medical N/A Prior Authorization/Medical Necessity Guidelines: Zomacton Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Medical Management Guidelines: Maximum Dosage Policy Supply Limit Guidelines: Triptans Supply Limits Pharmacy* **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pharmacy N/A ©1996-2017, Oxford Health Plans, LLC Page 142 of 147 Effective 06/01/2017 Medication/Drug Dosage Form CPT/HCPCS Code(s) Precertification Routing Zonatuss (benzonatate) Capsule J3490 and J8499 PBM Zonegran (zonisamide) Capsule J8499 PBM Zontivity (vorapaxar) Tablet J8499 N/A Zorbtive (somatropin) Injection J2941 PBM N/A Zorvolex (diclofenac) Tablet J8499 PBM Zovirax cream (acyclovir) Cream J3490 PBM Zovirax Ointment Topical J3490 PBM Zubsolv (buprenorphine/ naloxone) Tablet J8499 N/A Zuplenz (Ondansetron) Tablet or Film PBM* Zurampic (lesinurad) Tablet Zutripro (Brand Only) (hydrocodone bitartrate, Oral chlorpheniramine Solution maleate and pseudoephedrine hcl) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 PBM J8499 PBM* Prior Authorization/Medical Necessity Guidelines: Zorbtive (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New And Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Zovirax N/A J8499 Coverage Criteria/Guidelines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Zonegran Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Zurampic Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ©1996-2017, Oxford Health Plans, LLC Benefit Type Notes Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Page 143 of 147 Effective 06/01/2017 Medication/Drug Zyban (bupropion) Dosage Form Tablet, Nasal Spray, Inhaler CPT/HCPCS Code(s) Precertification Routing J3490 PBM Zyclara (Imiquimod) Cream J3490 PBM* Zydelig (idelalisib) Tablet J8499 PBM Zykadia (ceritinib) Capsule J8999 PBM Zylfo and Zylfo CR (zileuton) Tablets J8499 PBM Zymaxid (Gatifloxacin ophthalmic solution) Ophthalmic Solution J3490 N/A Zyprexa (olanzapine) (brand only) Zyprexa Zydis (olanzapine) (brand only) Zyrtec (cetirizine) solution Zytiga (abiraterone acetate) N/A Tablet J8499 PBM* Tablet Oral Solution Oral Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy J8499 J8499 J8999 PBM* N/A PBM* Coverage Criteria/Guidelines Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prior Authorization/ Notification Guidelines: Zydelig Prior Authorization/ Notification Guidelines: Zykadia Step Therapy Guidelines: Zylfo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications N/A Prior Authorization/ Notification Guidelines: Zytiga ©1996-2017, Oxford Health Plans, LLC Benefit Type Pharmacy Notes *Benefits for Tobacco Cessation for Health Care Reform apply to all plans subject to health care reform. Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A Pharmacy N/A N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pharmacy** Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not Page 144 of 147 Effective 06/01/2017 Medication/Drug Zyvox (linezolid) (brand) Dosage Form Tablet/Oral Suspension CPT/HCPCS Code(s) Precertification Routing Coverage Criteria/Guidelines J8499 PBM Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benefit Type Pharmacy Notes require precertification. Benefit Note: **NJ Small Members should refer to their certificate of coverage for precertification guidelines and quantity limit guidelines. N/A CPT® is a registered trademark of the American Medical Association POLICY HISTORY/REVISION INFORMATION Date 06/01/2017 Action/Description Revised coverage guidelines for the following medications/drugs: Medication/Drug Status Summary of Changes Actemra (Tocilizumab): SQ Injection Revised Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Actemra for complete details Revised step therapy guidelines; refer to Step Therapy Guidelines: Actemra for complete details Adzenys XR (Amphetamine ExtendedRevised Revised coverage criteria/precertification requirements: Release o Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Adzenys XR for complete details Albenza (Albendazole) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Albenza for complete details Alecensa (Alectinib) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Alecensa for complete details Austedo (Deutetrabenazine) New Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Belsomra (Suvorexant) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Belsomra for complete details Cimzia (Certolizumab Pegol) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Cimzia (Certolizumab Pegol) for complete details Cosentyx (Secukinumab) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Cosentyx for complete details Emverm (Mebendazole) Revised Revised prior authorization/medical necessity guidelines; refer to Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 145 of 147 Effective 06/01/2017 Date Action/Description Prior Authorization/Medical Necessity Guidelines: Emverm for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Enbrel (etanercept) for complete details Revised step therapy guidelines; refer to Step Therapy Guidelines: Enbrel for complete details Revised coverage criteria/precertification requirements: o Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Eucrisa for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Farydak for complete details Updated list of applicable HCPCS codes; replaced Q9980 with J7320 Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Ibrance for complete details Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Imbruvica for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Kineret (anakinra) for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Korlym for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Mekinist (Trametinib) for complete details Revised coverage criteria/precertification requirements; removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Ninlaro for complete details Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Nucynta ER for complete details Updated step therapy guidelines; refer to Step Therapy Guidelines: Obredon for complete details Enbrel (Etanercept) Revised Eucrisa (Crisaborole) Revised Farydak (Panobinostat) Updated Genvisc 850 (Sodium Hyaluronate) Ibrance (Palbociclib) Updated Updated Imbruvica (Ibrutinib) Revised Kineret (Anakinra) Updated Korlym (Mifepristone) Updated Mekinist (Trametinib) Updated Methylphenidate Extended-Release Capsule (generic Metadate CD) Revised Ninlaro (Ixazomib) Updated Nucynta ER (Tapentadol Extended Release) Revised Obredon Solution (Hydrocodone/ Guaifenesin) Updated Opana ER (Oxymorphone Extended Release) Revised Orencia (Abatacept) Revised Oxycontin (Oxycodone Extended Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Opana ER for complete details Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Orencia for complete details Revised step therapy guidelines; refer to Step Therapy Guidelines: Orencia for complete details Revised prior authorization/medical necessity guidelines; refer to ©1996-2017, Oxford Health Plans, LLC Page 146 of 147 Effective 06/01/2017 Date Action/Description Prior Authorization/Medical Necessity Guidelines: Oxycontin for complete details Revised Revised prior authorization/medical necessity guidelines; refer to Oxycodone ER 12HR Tablet Prior Authorization/Medical Necessity Guidelines: Oxycodone ER for complete details Revised Revised prior authorization/medical necessity guidelines; refer to Oxymorphone Extended Release Prior Authorization/Medical Necessity Guidelines: Oxymorphone for complete details Rescula (Unoprostone) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Rescula for complete details Rozerem (Ramelteon) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Rozerem (Ramelteon) for complete details Simponi (Golimumab) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Simponi (Golimumab) for complete details Tafinlar (Dabrafenib) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Tafinlar for complete details Travoprost (Generic Travatan) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Travoprost (Generic Travatan) for complete details Vermox (Mebendazole) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Vermox for complete details Viberzi (Eluxadoline) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Viberzi for complete details Revised Revised prior authorization/medical necessity guidelines; refer to Xtampza ER (Oxycodone) Prior Authorization/Medical Necessity Guidelines: Xtampza ER for complete details Zelboraf (Vemurafenib) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Zelboraf for complete details Zioptan (Tafluprost) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Zioptan (Tafluprost) for complete details Zolpimist (Zolpidem Tartrate) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Zolpimist (Zolpidem Tartrate) for complete details Archived previous policy version PHARMACY 098.160 T0 Release) Drug Coverage Guidelines UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 147 of 147 Effective 06/01/2017
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